Provider Demographics
NPI:1083496897
Name:BANVILLE, TAWNY NICOLE
Entity Type:Individual
Prefix:
First Name:TAWNY
Middle Name:NICOLE
Last Name:BANVILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:BERRYVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22611-1309
Mailing Address - Country:US
Mailing Address - Phone:540-539-2007
Mailing Address - Fax:
Practice Address - Street 1:603 W PATRICK ST STE B
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4090
Practice Address - Country:US
Practice Address - Phone:301-620-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU03049171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty