Provider Demographics
NPI:1811932064
Name:BANKS, MICHELLE (NP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BANKS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 S FRONTAGE RD
Mailing Address - Street 2:SUITE T
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5328
Mailing Address - Country:US
Mailing Address - Phone:601-262-1000
Mailing Address - Fax:601-262-1009
Practice Address - Street 1:2080 S FRONTAGE RD
Practice Address - Street 2:SUITE T
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5328
Practice Address - Country:US
Practice Address - Phone:601-262-1000
Practice Address - Fax:601-262-1009
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR805638363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121754Medicaid
MS00121754Medicaid
MS500000735Medicare PIN
MS$$$$$$$$$BOtherBCBS
MS500015852Medicare PIN