Provider Demographics
NPI:1992205900
Name:BANCOOK, COURTNEY B (LVN)
Entity Type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:B
Last Name:BANCOOK
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 S BECKHAM AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1903
Mailing Address - Country:US
Mailing Address - Phone:903-534-4684
Mailing Address - Fax:903-534-4726
Practice Address - Street 1:224 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771-2627
Practice Address - Country:US
Practice Address - Phone:903-570-5999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX169545164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX169545OtherLVN