Provider Demographics
NPI:1003164963
Name:BANAWA, DIANNE KRISTINE TABLAN
Entity type:Individual
Prefix:MRS
First Name:DIANNE KRISTINE
Middle Name:TABLAN
Last Name:BANAWA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72253 TWENTYNINE PALMS HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277
Mailing Address - Country:US
Mailing Address - Phone:760-367-3262
Mailing Address - Fax:760-367-0079
Practice Address - Street 1:72253 TWENTYNINE PALMS HIGHWAY
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277
Practice Address - Country:US
Practice Address - Phone:760-367-3262
Practice Address - Fax:760-367-0079
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66722183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist