Provider Demographics
NPI:1972967883
Name:ELIZABETH L BANDA APRN NP-C LLC
Entity type:Organization
Organization Name:ELIZABETH L BANDA APRN NP-C LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:BANDA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN NP-C
Authorized Official - Phone:918-721-3955
Mailing Address - Street 1:112 TEAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-2244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 S HIGHWAY 45
Practice Address - Street 2:
Practice Address - City:BONANZA
Practice Address - State:AR
Practice Address - Zip Code:72916-3420
Practice Address - Country:US
Practice Address - Phone:479-255-6150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004191363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200597420AMedicaid
AR367562YX2TMedicare UPIN
OK453389YQDZMedicare UPIN