MEDICARE: EMILIA BANSE PMHNP-BC PLLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1164044004
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMILIA BANSE PMHNP-BC PLLC

Provider Business Mailing Address
First Line	:	120 GOLDEN EAGLE CT
Second Line	:
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-8344
Country	:	US
Telephone Number	:	202-876-8787
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 GOLDEN EAGLE CT
Second Line	:
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-8344
Country	:	US
Telephone Number	:	202-876-8787
Fax Number	:

Authorized Official
Title or Position	:	NURSE PRACTITIONER/OWNER
Name	:	EMILIA M BANSE
Credential	:	PMHNP-BC
Telephone Number	:	202-876-8787

Provider Enumeration Date	:	05/14/2020
Last Update Date	:	05/14/2020

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