Provider Demographics
NPI:1003314956
Name:BENAVIDES, MARIELLA
Entity Type:Individual
Prefix:
First Name:MARIELLA
Middle Name:
Last Name:BENAVIDES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 SAINT JOHNS PL APT 3R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-5558
Mailing Address - Country:US
Mailing Address - Phone:239-537-4128
Mailing Address - Fax:
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:646-501-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-25
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341959363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner