Provider Demographics
NPI:1184677130
Name:BANVILLE, EARLENE F (CRNA)
Entity Type:Individual
Prefix:
First Name:EARLENE
Middle Name:F
Last Name:BANVILLE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1849
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04241-1849
Mailing Address - Country:US
Mailing Address - Phone:207-784-2554
Mailing Address - Fax:207-777-5363
Practice Address - Street 1:ONE PARKLAND DRIVE
Practice Address - Street 2:
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038
Practice Address - Country:US
Practice Address - Phone:603-421-2163
Practice Address - Fax:978-946-8206
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA123030367500000X
NH052873-23-11367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NA0746Medicare PIN