Healthcare Provider Details

I. General information

NPI: 1578850558
Provider Name (Legal Business Name): ANN ELIZABETH BENNER PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 E MAIN ST
CANTON NY
13617-1450
US

IV. Provider business mailing address

50 LEROY ST
POTSDAM NY
13676-1799
US

V. Phone/Fax

Practice location:
  • Phone: 315-261-5615
  • Fax: 315-261-7183
Mailing address:
  • Phone: 315-265-3300
  • Fax: 315-261-6025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number22570374
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number382969
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number22570374
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: