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General NPI Number Information
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NPI Number | 1427788009
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Entity Type | Individual
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Provider Name | AMY ROSE BENENSON MSPAS, PA-C
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Gender | Female
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Dates
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Enumeration Date | 06/15/2022
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Last Update Date | 01/04/2024
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Provider Practice Location Address
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Address Line | 289 WINDHAM RD
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City | WILLIMANTIC
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State | CT
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Zip | 06226-3528
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Country | US
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Telephone | 860-343-0302
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Fax |
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Provider Business Mailing Address
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Address Line | 302 FIELDSTONE
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City | LEDYARD
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State | CT
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Zip | 06339-1250
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Country | US
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Telephone | 516-304-8956
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number | PA01468
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License Number State | RI
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 5717
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License Number State | CT
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