MEDICARE: MRS. SANDRA OLIVAS BENAVENTE LVN

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	164X00000X	Licensed Vocational Nurse	90182	TX

General Provider Information

NPI Number	:	1861974867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SANDRA OLIVAS BENAVENTE LVN

Provider Business Mailing Address
First Line	:	5466 N ALEXANDER LN
Second Line	:
City	:	FORT STOCKTON
State	:	TX
Zip	:	79735-9405
Country	:	US
Telephone Number	:	432-290-0638
Fax Number	:

Provider Business Practice Location Address
First Line	:	5466 N ALEXANDER LN
Second Line	:
City	:	FORT STOCKTON
State	:	TX
Zip	:	79735-9405
Country	:	US
Telephone Number	:	432-290-0638
Fax Number	:

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

Provider Enumeration Date	:	09/05/2018
Last Update Date	:	09/05/2018

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