Healthcare Provider Details

I. General information

NPI: 1124868187
Provider Name (Legal Business Name): TARA LEIGH BENSON APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 SHAWANO AVE
GREEN BAY WI
54303-2667
US

IV. Provider business mailing address

PO BOX 19070
GREEN BAY WI
54307-9070
US

V. Phone/Fax

Practice location:
  • Phone: 920-429-1700
  • Fax:
Mailing address:
  • Phone: 920-496-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15391-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: