Healthcare Provider Details

I. General information

NPI: 1487914735
Provider Name (Legal Business Name): ANGELA D BANKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 MORRIS RD. SW
LOS LUNAS NM
87031-5242
US

IV. Provider business mailing address

750 MORRIS RD. SW
LOS LUNAS NM
87031-0000
US

V. Phone/Fax

Practice location:
  • Phone: 505-866-2300
  • Fax: 505-866-2309
Mailing address:
  • Phone: 505-866-2300
  • Fax: 505-866-2309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: