Provider Demographics
NPI:1962428003
Name:BANKSTON, KIMBERLY J (ANP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:BANKSTON
Suffix:
Gender:F
Credentials:ANP
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 2451
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-2451
Mailing Address - Country:US
Mailing Address - Phone:309-268-2172
Mailing Address - Fax:309-268-3949
Practice Address - Street 1:385 S ORANGE ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:IL
Practice Address - Zip Code:61738-1613
Practice Address - Country:US
Practice Address - Phone:309-527-4900
Practice Address - Fax:309-527-3525
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL20900121363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
5720935OtherBLUE CROSS BLUE SHIELD
10220308OtherBLUE CROSS BLUE SHIELD
200940Medicare ID - Type Unspecified
10220308OtherBLUE CROSS BLUE SHIELD
IL374440Medicare ID - Type UnspecifiedMEDICARE GROUP SCM
IL748940Medicare ID - Type UnspecifiedMEDICARE GROUP HPT
5720935OtherBLUE CROSS BLUE SHIELD
ILK30790Medicare ID - Type UnspecifiedMEDICARE PIN FMA
ILK30792Medicare ID - Type UnspecifiedMEDICARE PIN TCH
IL206706Medicare ID - Type UnspecifiedMEDICARE GROUP LFM
ILK30787Medicare ID - Type UnspecifiedMEDICARE PIN LFM
IL200871Medicare ID - Type UnspecifiedMEDICARE GROUP INT
IL748943Medicare ID - Type UnspecifiedMEDICARE GROUP EP
ILK30786Medicare ID - Type UnspecifiedMEDICARE PIN HPT
ILK30791Medicare ID - Type UnspecifiedMEDICARE PIN SCM
ILK30793Medicare ID - Type UnspecifiedMEDICARE PIN INT
P51370Medicare UPIN
ILK12935Medicare ID - Type UnspecifiedMEDICARE PIN FMA
IL748942Medicare ID - Type UnspecifiedMEDICARE GROUP LEX