Provider Demographics
NPI:1336603588
Name:BANKS, DANIEL WAYNE
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:WAYNE
Last Name:BANKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1736 CLUB HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33917-2518
Mailing Address - Country:US
Mailing Address - Phone:334-328-5736
Mailing Address - Fax:
Practice Address - Street 1:25097 OLYMPIA AVE STE 205
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-3912
Practice Address - Country:US
Practice Address - Phone:941-347-8341
Practice Address - Fax:941-347-7702
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001033363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty