Healthcare Provider Details

I. General information

NPI: 1699883801
Provider Name (Legal Business Name): CAROL EMILY BENTON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DAYTOP VILLAGE
SWAN LAKE NY
12783
US

IV. Provider business mailing address

63 SCHEIBE ROAD
LIBERTY NY
12754
US

V. Phone/Fax

Practice location:
  • Phone: 845-292-6875
  • Fax:
Mailing address:
  • Phone: 845-292-0395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number157337-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: