Healthcare Provider Details

I. General information

NPI: 1053487876
Provider Name (Legal Business Name): VANESSA BENAVIDEZ CST, FA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 CHINOOK LN
PUEBLO CO
81001-1851
US

IV. Provider business mailing address

1302 CHINOOK LN
PUEBLO CO
81001-1851
US

V. Phone/Fax

Practice location:
  • Phone: 719-545-2746
  • Fax: 719-545-4100
Mailing address:
  • Phone: 719-545-2746
  • Fax: 719-545-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number87802
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: