Provider Demographics
NPI:1093041048
Name:BANKSTON, STACEY
Entity Type:Individual
Prefix:MR
First Name:STACEY
Middle Name:
Last Name:BANKSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 TRINITY DR
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-7802
Mailing Address - Country:US
Mailing Address - Phone:870-879-0638
Mailing Address - Fax:
Practice Address - Street 1:6400 TRINITY DR
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-7802
Practice Address - Country:US
Practice Address - Phone:870-879-0638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A581225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist