Healthcare Provider Details

I. General information

NPI: 1245941509
Provider Name (Legal Business Name): SANDRA JEAN BENNY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2022
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E FESLER ST
SANTA MARIA CA
93454-4404
US

IV. Provider business mailing address

190 CARY PL
NIPOMO CA
93444-5028
US

V. Phone/Fax

Practice location:
  • Phone: 805-922-6597
  • Fax:
Mailing address:
  • Phone: 805-610-9012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number91165
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: