Provider Demographics
NPI:1508440587
Name:BANFIELD, DANA RENE'
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:RENE'
Last Name:BANFIELD
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:PO BOX 132
Mailing Address - Street 2:
Mailing Address - City:BLACK CANYON CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85324-0132
Mailing Address - Country:US
Mailing Address - Phone:602-717-3641
Mailing Address - Fax:
Practice Address - Street 1:18441 N 87TH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-8532
Practice Address - Country:US
Practice Address - Phone:315-335-9130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ010335225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant