Provider Demographics
NPI:1275201360
Name:BANKS, CRISTEN RENEE
Entity Type:Individual
Prefix:
First Name:CRISTEN
Middle Name:RENEE
Last Name:BANKS
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 1:3602 MARQUETTE RD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-1990
Mailing Address - Country:US
Mailing Address - Phone:815-223-7400
Mailing Address - Fax:
Practice Address - Street 1:4505 N ROCKWOOD DR STE 1
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-3815
Practice Address - Country:US
Practice Address - Phone:309-589-1880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023920363L00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209023920OtherDEPT OF FINANCIAL AMD PROFESSIONAL REGULATION