Provider Demographics
NPI:1164663324
Name:BANACK, NANCY (PT)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:
Last Name:BANACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 HILLHOUSE AVE
Mailing Address - Street 2:YALE UNIVERSITY HEALTH SERVICES
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511
Mailing Address - Country:US
Mailing Address - Phone:203-432-0076
Mailing Address - Fax:203-432-7289
Practice Address - Street 1:17 HILLHOUSE AVE
Practice Address - Street 2:YALE UNIVERSITY HEALTH SERVICES
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-432-0076
Practice Address - Fax:203-432-7289
Is Sole Proprietor?:No
Enumeration Date:2009-03-18
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003250174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist