Provider Demographics
NPI:1104067164
Name:BANKHEAD, SOPHIA LYNN (LPN)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:LYNN
Last Name:BANKHEAD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44502-2221
Mailing Address - Country:US
Mailing Address - Phone:330-507-8404
Mailing Address - Fax:
Practice Address - Street 1:633 LEE AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44502-2221
Practice Address - Country:US
Practice Address - Phone:330-507-8404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-20
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 129163 IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse