Provider Demographics
NPI:1295935880
Name:BANKS, CAROL ANN (RN)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:BANKS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6489
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46660-6489
Mailing Address - Country:US
Mailing Address - Phone:574-472-6700
Mailing Address - Fax:
Practice Address - Street 1:420 W FOURTH STREET
Practice Address - Street 2:SUITE 100-A
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1948
Practice Address - Country:US
Practice Address - Phone:574-252-0309
Practice Address - Fax:574-472-3694
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28120528A163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200068990AMedicaid