Healthcare Provider Details

I. General information

NPI: 1619052297
Provider Name (Legal Business Name): JAMIE LEANN BENHAM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 03/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 SE 5TH ST
KNOX CITY TX
79529-2105
US

IV. Provider business mailing address

PO BOX 488
KNOX CITY TX
79529-0488
US

V. Phone/Fax

Practice location:
  • Phone: 940-657-3906
  • Fax: 940-657-3909
Mailing address:
  • Phone: 940-657-3906
  • Fax: 940-657-3909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number558339
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: