Provider Demographics
NPI:1689491003
Name:BANKS, TINA ASHLEY
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:ASHLEY
Last Name:BANKS
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 1:2120 OLD HIGHWAY 3
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:MS
Mailing Address - Zip Code:39066-9207
Mailing Address - Country:US
Mailing Address - Phone:601-953-8577
Mailing Address - Fax:
Practice Address - Street 1:2120 OLD HIGHWAY 3
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:MS
Practice Address - Zip Code:39066-9207
Practice Address - Country:US
Practice Address - Phone:601-953-8577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS247000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health InformationGroup - Multi-Specialty