Healthcare Provider Details

I. General information

NPI: 1730004953
Provider Name (Legal Business Name): TIARA RENAE BENAVIDES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

998 E KNOTTS AVE
STILLWATER OK
74075-3023
US

IV. Provider business mailing address

1520 N BOOMER RD # 2108
STILLWATER OK
74075-5115
US

V. Phone/Fax

Practice location:
  • Phone: 844-458-2100
  • Fax:
Mailing address:
  • Phone: 844-458-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberN084294350
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: