Provider Demographics
NPI:1891764296
Name:BANKSON, KATHIE LILLIAN (NP)
Entity Type:Individual
Prefix:MS
First Name:KATHIE
Middle Name:LILLIAN
Last Name:BANKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14166 W INDIANOLA AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-8455
Mailing Address - Country:US
Mailing Address - Phone:623-536-5484
Mailing Address - Fax:623-536-5484
Practice Address - Street 1:501 E PLAZA CIR DR
Practice Address - Street 2:SUITE A
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-4998
Practice Address - Country:US
Practice Address - Phone:623-536-7956
Practice Address - Fax:623-536-9806
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP667363LF0000X
AZAP1979363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Not Answered363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ729618Medicaid
AZQ06016Medicare UPIN
AZZ77634Medicare ID - Type Unspecified