Healthcare Provider Details

I. General information

NPI: 1275118416
Provider Name (Legal Business Name): KELLI JEAN BENSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 NORTH 17TH STREET
MILWAUKEE WI
53233
US

IV. Provider business mailing address

507 N 17TH ST
MILWAUKEE WI
53233-2104
US

V. Phone/Fax

Practice location:
  • Phone: 414-288-0607
  • Fax:
Mailing address:
  • Phone: 414-288-0607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010688
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: