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General NPI Number Information
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NPI Number | 1548636780
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Entity Type | Individual
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Provider Name | MIRANDA KAY BENSON MAT, AT, ATC
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Gender | Female
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Dates
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Enumeration Date | 08/11/2015
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Last Update Date | 12/15/2023
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Provider Practice Location Address
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Address Line | 1800 COLLEGE AVE
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City | QUINCY
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State | IL
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Zip | 62301-2670
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Country | US
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Telephone | 217-228-5432
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Fax | 217-228-5604
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Provider Business Mailing Address
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Address Line | 606 N 5TH ST
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City | CANTON
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State | MO
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Zip | 63435-1100
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Country | US
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Telephone | 920-639-9272
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 096.004631
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License Number State | IL
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