Provider Demographics
NPI:1972097491
Name:BANKSTON, LATRISALA (NP)
Entity Type:Individual
Prefix:
First Name:LATRISALA
Middle Name:
Last Name:BANKSTON
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 1:15535 DOWNFORD DR
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77377-8687
Mailing Address - Country:US
Mailing Address - Phone:318-230-0993
Mailing Address - Fax:
Practice Address - Street 1:15535 DOWNFORD DR
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77377
Practice Address - Country:US
Practice Address - Phone:318-230-0993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX137803363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily