Provider Demographics
NPI:1386942621
Name:BANAWA, TANALIE (LVN)
Entity type:Individual
Prefix:
First Name:TANALIE
Middle Name:
Last Name:BANAWA
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70324
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90070-0324
Mailing Address - Country:US
Mailing Address - Phone:949-456-0962
Mailing Address - Fax:
Practice Address - Street 1:981 S WILTON PL APT 3
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-2140
Practice Address - Country:US
Practice Address - Phone:949-456-0962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2014-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN246806164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALVN246806OtherLVN