Healthcare Provider Details

I. General information

NPI: 1043602147
Provider Name (Legal Business Name): MARY TAYLOR BENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY TAYLOR

II. Dates (important events)

Enumeration Date: 02/26/2015
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

987 PARALLEL DR STE C
LAKEPORT CA
95453-5708
US

IV. Provider business mailing address

1010 MINT SPRINGS RD
TERRY MS
39170-8778
US

V. Phone/Fax

Practice location:
  • Phone: 707-262-5088
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.0041364
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95010828
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60909312
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8067
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberR863948
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: