MEDICARE: BENJAMIN DAVID LIST PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN.CNP.019455	OH
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	28200219A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	71004343A	OTHER	IN	APN PRESCRIPTIVE AUTHORITY
2	APRN.CNP.019455	OTHER	OH	CERTIFIED NURSE PRACTITIONER
3	CTP.019994	OTHER	OH	CERTIFICATE TO PRESCRIBE
4	71004343B	OTHER	IN	CSR-PRESCRIPTIVE AUTHORITY

General Provider Information

NPI Number	:	1780924746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN DAVID LIST PMHNP-BC

Provider Business Mailing Address
First Line	:	1501 MADISON RD.
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45206-2223
Country	:	US
Telephone Number	:	513-354-5200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 MADISON RD.
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45206-2223
Country	:	US
Telephone Number	:	513-354-5200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2013
Last Update Date	:	03/07/2023

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