Healthcare Provider Details

I. General information

NPI: 1386040129
Provider Name (Legal Business Name): LEESA BENENHALEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 11/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 N MCDOWELL BLVD
PETALUMA CA
94954-6559
US

IV. Provider business mailing address

1179 N MCDOWELL BLVD
PETALUMA CA
94954-6559
US

V. Phone/Fax

Practice location:
  • Phone: 707-559-7500
  • Fax: 707-559-7620
Mailing address:
  • Phone: 707-559-7500
  • Fax: 707-559-7620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95001100
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: