Provider Demographics
NPI:1679340699
Name:BANKA, NICOLE EWA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:EWA
Last Name:BANKA
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 1:26493 SW 135TH CT
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-2558
Mailing Address - Country:US
Mailing Address - Phone:786-738-7928
Mailing Address - Fax:
Practice Address - Street 1:10373 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-1704
Practice Address - Country:US
Practice Address - Phone:786-473-6153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician