Provider Demographics
NPI:1578707279
Name:BANKS, LATRICE RENEE (RD)
Entity Type:Individual
Prefix:MRS
First Name:LATRICE
Middle Name:RENEE
Last Name:BANKS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 CRISPIN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2467
Mailing Address - Country:US
Mailing Address - Phone:248-514-8081
Mailing Address - Fax:
Practice Address - Street 1:845 CRISPIN
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-2467
Practice Address - Country:US
Practice Address - Phone:248-514-8081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI977137133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI237464Medicare Oscar/Certification