MEDICARE: BENN SANFORD MSN AGNP-C

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	363LG0600X	Gerontology Nurse Practitioner	AP143362	TX

General Provider Information

NPI Number	:	1871134312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENN SANFORD MSN AGNP-C

Provider Business Mailing Address
First Line	:	3570 COLLEGE ST STE 200
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77701-4679
Country	:	US
Telephone Number	:	409-839-3118
Fax Number	:

Provider Business Practice Location Address
First Line	:	2929 CALDER ST STE 100
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77702-1841
Country	:	US
Telephone Number	:	409-839-3118
Fax Number	:	409-654-6921

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

Provider Enumeration Date	:	10/07/2019
Last Update Date	:	10/07/2019

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