Provider Demographics
NPI:1972861169
Name:BANE, MAGGIE FORD (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:MAGGIE
Middle Name:FORD
Last Name:BANE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MISS
Other - First Name:MAGGIE
Other - Middle Name:FORD
Other - Last Name:WILKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2206 WILBORN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1630
Mailing Address - Country:US
Mailing Address - Phone:434-517-8627
Mailing Address - Fax:434-517-8080
Practice Address - Street 1:2206 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1630
Practice Address - Country:US
Practice Address - Phone:434-517-8627
Practice Address - Fax:434-517-8080
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005825363LA2200X
VA0024170022363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health