MEDICARE: MISS LATASHA FAYE BANKS

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	251E00000X	Home Health Agency	210054541	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	21-005454-1	OTHER	IN	ISDH

General Provider Information

NPI Number	:	1336808500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS LATASHA FAYE BANKS

Provider Business Mailing Address
First Line	:	1709 N SHADELAND AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-2733
Country	:	US
Telephone Number	:	317-709-7365
Fax Number	:

Provider Business Practice Location Address
First Line	:	1709 N SHADELAND AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-2733
Country	:	US
Telephone Number	:	317-709-7365
Fax Number	:

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

Provider Enumeration Date	:	12/14/2021
Last Update Date	:	12/14/2021

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