Healthcare Provider Details

I. General information

NPI: 1427788009
Provider Name (Legal Business Name): AMY ROSE BENENSON MSPAS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 WINDHAM RD
WILLIMANTIC CT
06226-3528
US

IV. Provider business mailing address

302 FIELDSTONE
LEDYARD CT
06339-1250
US

V. Phone/Fax

Practice location:
  • Phone: 860-343-0302
  • Fax:
Mailing address:
  • Phone: 516-304-8956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberPA01468
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5717
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: