Provider Demographics
NPI:1053487876
Name:BENAVIDEZ, VANESSA (CST, FA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:BENAVIDEZ
Suffix:
Gender:F
Credentials:CST, FA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 CHINOOK LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1851
Mailing Address - Country:US
Mailing Address - Phone:719-545-2746
Mailing Address - Fax:719-545-4100
Practice Address - Street 1:1302 CHINOOK LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1851
Practice Address - Country:US
Practice Address - Phone:719-545-2746
Practice Address - Fax:719-545-4100
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO87802246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist