Healthcare Provider Details

I. General information

NPI: 1720127012
Provider Name (Legal Business Name): MICHELE L BENA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 03/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DEPAUL DR.
BRIDGETON MO
63044
US

IV. Provider business mailing address

7 ELM AVE
SAINT LOUIS MO
63122-4836
US

V. Phone/Fax

Practice location:
  • Phone: 314-344-6476
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2007001283
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2007001283
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: