Provider Demographics
NPI:1346817079
Name:BANASZAK, LAUREN ELIZABETH (CNM)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:BANASZAK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:ELIZABETH
Other - Last Name:HALVERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1105 BURLEYSON RD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3181
Mailing Address - Country:US
Mailing Address - Phone:706-278-4640
Mailing Address - Fax:
Practice Address - Street 1:1105 BURLEYSON RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3181
Practice Address - Country:US
Practice Address - Phone:706-278-4640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN301551367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife