Provider Demographics
NPI:1487319034
Name:BANKS, NICOLE LORRAINE (HAS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LORRAINE
Last Name:BANKS
Suffix:
Gender:F
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 W CENTRE AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-5302
Mailing Address - Country:US
Mailing Address - Phone:269-324-0301
Mailing Address - Fax:269-324-2733
Practice Address - Street 1:1350 W CENTRE AVE STE 105
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5302
Practice Address - Country:US
Practice Address - Phone:269-324-0301
Practice Address - Fax:269-324-2733
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3502012160237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist