Provider Demographics
NPI:1386382398
Name:ANKLESARIA, BANU KAIZAD
Entity type:Individual
Prefix:
First Name:BANU
Middle Name:KAIZAD
Last Name:ANKLESARIA
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 1:1620 W BENBOW ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1086 W ARROW HWY
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2492
Practice Address - Country:US
Practice Address - Phone:909-305-1352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA646857163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse