Provider Demographics
NPI:1427567049
Name:BANABAN, JACQUELYNN (AG-ACNP-BC)
Entity Type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:
Last Name:BANABAN
Suffix:
Gender:F
Credentials:AG-ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 CLOVERFIELD BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-1821
Mailing Address - Country:US
Mailing Address - Phone:808-349-8152
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON ST # 2
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:310-222-2171
Practice Address - Fax:310-222-5601
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007291363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care