Provider Demographics
NPI:1851705552
Name:BANDA, ELIZABETH (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BANDA
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S BROADWAY ST
Mailing Address - Street 2:STE B
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-3819
Mailing Address - Country:US
Mailing Address - Phone:918-208-7497
Mailing Address - Fax:918-208-7687
Practice Address - Street 1:500 S BROADWAY ST
Practice Address - Street 2:STE B
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-3819
Practice Address - Country:US
Practice Address - Phone:918-208-7497
Practice Address - Fax:918-208-7687
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-20
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK74771363LF0000X
ARA004191363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200597420AMedicaid