Healthcare Provider Details

I. General information

NPI: 1104248129
Provider Name (Legal Business Name): KIMBERLY KAY BENKNER PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2014
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44201 DEQUINDRE RD STE EC
TROY MI
48085-1117
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 248-259-3088
  • Fax: 248-964-6133
Mailing address:
  • Phone: 947-522-1865
  • Fax: 947-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704386315
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: