Healthcare Provider Details

I. General information

NPI: 1629492673
Provider Name (Legal Business Name): JENNIFER A BANDA CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER A REYNICK

II. Dates (important events)

Enumeration Date: 02/11/2014
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 S J ST FLOOR 1
TACOMA WA
98405-4930
US

IV. Provider business mailing address

1608 S J ST FLOOR 1
TACOMA WA
98405-4930
US

V. Phone/Fax

Practice location:
  • Phone: 253-274-7501
  • Fax: 253-274-7991
Mailing address:
  • Phone: 253-274-7501
  • Fax: 253-274-7991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number001609
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number001609
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAP60427514
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: