Healthcare Provider Details

I. General information

NPI: 1053834945
Provider Name (Legal Business Name): BENITHO LOUISSAINT NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2017
Last Update Date: 10/29/2023
Certification Date: 10/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6197 S RURAL RD
TEMPE AZ
85283-2909
US

IV. Provider business mailing address

6197 S RURAL RD
TEMPE AZ
85283-2909
US

V. Phone/Fax

Practice location:
  • Phone: 480-471-8980
  • Fax: 480-912-1061
Mailing address:
  • Phone: 480-471-8980
  • Fax: 480-912-1061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP10399
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP10399
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: