Healthcare Provider Details

I. General information

NPI: 1568224103
Provider Name (Legal Business Name): BENJAMIN EARNEST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BEN EARNEST

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2581 HUNTCLIFF LN
PANAMA CITY FL
32405-4902
US

IV. Provider business mailing address

2934 HARRISON AVE UNIT F
PANAMA CITY FL
32405-8012
US

V. Phone/Fax

Practice location:
  • Phone: 850-520-3321
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberIMH24040
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: