Provider Demographics
NPI:1013413129
Name:BENJAMIN, ANGELINA MICHELLE
Entity Type:Individual
Prefix:
First Name:ANGELINA
Middle Name:MICHELLE
Last Name:BENJAMIN
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 1:1515 E TUDOR RD STE 6
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-1036
Mailing Address - Country:US
Mailing Address - Phone:907-332-0065
Mailing Address - Fax:907-782-4522
Practice Address - Street 1:1515 E TUDOR RD STE 6
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-1036
Practice Address - Country:US
Practice Address - Phone:907-332-0065
Practice Address - Fax:907-782-4522
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKCERTIFICATE171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK6919734OtherSTATE ISSUED DRIVERS LICENSE