Healthcare Provider Details

I. General information

NPI: 1619448578
Provider Name (Legal Business Name): JOAN MARCY BENKEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 HOBART RD
SOUTHOLD NY
11971-1510
US

IV. Provider business mailing address

250 HOBART RD
SOUTHOLD NY
11971-1510
US

V. Phone/Fax

Practice location:
  • Phone: 631-765-5619
  • Fax:
Mailing address:
  • Phone: 631-765-5619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberF420374
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number377979
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: