Provider Demographics
NPI:1568500932
Name:BANKS, TUNESHA IJUAN
Entity Type:Individual
Prefix:
First Name:TUNESHA
Middle Name:IJUAN
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 1:503 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-8201
Mailing Address - Country:US
Mailing Address - Phone:662-424-9500
Mailing Address - Fax:662-424-9592
Practice Address - Street 1:503 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-8201
Practice Address - Country:US
Practice Address - Phone:662-424-9500
Practice Address - Fax:662-424-9592
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1485174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02559841Medicaid