MEDICARE: MRS. KELLI LYNN BANKES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	176B00000X	Midwife

General Provider Information

NPI Number	:	1154687788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLI LYNN BANKES

Provider Business Mailing Address
First Line	:	4863 DIAMOND TRACE TRL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-7976
Country	:	US
Telephone Number	:	817-614-1292
Fax Number	:

Provider Business Practice Location Address
First Line	:	4863 DIAMOND TRACE TRL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-7976
Country	:	US
Telephone Number	:	817-614-1292
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2012
Last Update Date	:	04/09/2012

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