Basic Information
| Provider Information | |||||||||
| NPI: | 1629492673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANDA | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REYNICK | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1608 S J ST | ||||||||
| Address2: | FLOOR 1 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532747501 | ||||||||
| FaxNumber: | 2532747991 | ||||||||
| Practice Location | |||||||||
| Address1: | 1608 S J ST | ||||||||
| Address2: | FLOOR 1 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532747501 | ||||||||
| FaxNumber: | 2532747991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2014 | ||||||||
| LastUpdateDate: | 06/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 001609 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 176B00000X | 001609 | NY | N | Other Service Providers | Midwife | 367A00000X | AP60427514 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 347010 | 01 | WA | STATE L&I | OTHER |