Provider Demographics
NPI:1053435750
Name:BANTONSMITH, MARLENE ANGELA
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:ANGELA
Last Name:BANTONSMITH
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 1:6461 NW 24 PLACE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33313
Mailing Address - Country:US
Mailing Address - Phone:954-572-8350
Mailing Address - Fax:
Practice Address - Street 1:5700 NW 27 COURT
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33313
Practice Address - Country:US
Practice Address - Phone:954-486-0858
Practice Address - Fax:954-497-3857
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator