Healthcare Provider Details

I. General information

NPI: 1083382717
Provider Name (Legal Business Name): SCOTT KENNETH BENSON AG-ACNPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9460 AMDERDALE DRIVE, SUITE E
NORTH CHESTERFIELD VA
23236
US

IV. Provider business mailing address

PO BOX 402924
ATLANTA GA
30384-2924
US

V. Phone/Fax

Practice location:
  • Phone: 804-533-0220
  • Fax: 804-533-0230
Mailing address:
  • Phone: 804-533-0220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number0024181457
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024181457
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: