Healthcare Provider Details

I. General information

NPI: 1073974705
Provider Name (Legal Business Name): GRACE BANEZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2190 N LINCOLN AVE
SALEM OH
44460-9312
US

IV. Provider business mailing address

PO BOX 955
SALEM OH
44460-0955
US

V. Phone/Fax

Practice location:
  • Phone: 330-429-2661
  • Fax:
Mailing address:
  • Phone: 330-429-2661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN 095993
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: