Basic Information
| Provider Information | |||||||||
| NPI: | 1184053472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANKS | ||||||||
| FirstName: | MADONNA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3889 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376023889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237945520 | ||||||||
| FaxNumber: | 4232826940 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 MED TECH PKWY STE 240 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237945520 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2013 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 160343 | TN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 17836 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100285590 | 05 | KY | MEDICAID | 1184053472 | 05 | VA | MEDICAID | 1184053472 | 05 | NC | MEDICAID | P01706810 | 01 | TN | RAILROAD MEDICARE | OTHER | Q002716 | 05 | TN | MEDICAID |