Healthcare Provider Details

I. General information

NPI: 1184677130
Provider Name (Legal Business Name): EARLENE F BANVILLE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE PARKLAND DRIVE
DERRY NH
03038
US

IV. Provider business mailing address

PO BOX 1849
LEWISTON ME
04241-1849
US

V. Phone/Fax

Practice location:
  • Phone: 603-421-2163
  • Fax: 978-946-8206
Mailing address:
  • Phone: 207-784-2554
  • Fax: 207-777-5363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number123030
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number052873-23-11
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: