Provider Demographics
NPI:1023658804
Name:BANKS, BERTHA MAE (LPN)
Entity type:Individual
Prefix:
First Name:BERTHA
Middle Name:MAE
Last Name:BANKS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 NE OPAL CT
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-8760
Mailing Address - Country:US
Mailing Address - Phone:203-470-9886
Mailing Address - Fax:
Practice Address - Street 1:925 NE OPAL CT
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-8760
Practice Address - Country:US
Practice Address - Phone:203-470-9886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP60317368164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse