Provider Demographics
NPI:1558086678
Name:BANKSTON, MITTESE DOREEN
Entity Type:Individual
Prefix:MRS
First Name:MITTESE
Middle Name:DOREEN
Last Name:BANKSTON
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 1:622 17TH ST SE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44707-3708
Mailing Address - Country:US
Mailing Address - Phone:330-617-9533
Mailing Address - Fax:
Practice Address - Street 1:622 17TH ST SE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44707-3708
Practice Address - Country:US
Practice Address - Phone:330-617-9533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle