Healthcare Provider Details

I. General information

NPI: 1497667372
Provider Name (Legal Business Name): ALICIA KIM BANACH CRC, PRSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 S WINOOSKI AVE
BURLINGTON VT
05401-4669
US

IV. Provider business mailing address

179 S WINOOSKI AVE
BURLINGTON VT
05401-4669
US

V. Phone/Fax

Practice location:
  • Phone: 802-861-3150
  • Fax:
Mailing address:
  • Phone: 802-861-3150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number194.0000083
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: