Provider Demographics
NPI:1053502708
Name:BENASZESKI, MARY ALICE (RN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ALICE
Last Name:BENASZESKI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 HIGHWAY 8
Mailing Address - Street 2:
Mailing Address - City:MONICO
Mailing Address - State:WI
Mailing Address - Zip Code:54501-7759
Mailing Address - Country:US
Mailing Address - Phone:715-550-6279
Mailing Address - Fax:715-487-5638
Practice Address - Street 1:1800 HIGHWAY 8
Practice Address - Street 2:
Practice Address - City:MONICO
Practice Address - State:WI
Practice Address - Zip Code:54501-7759
Practice Address - Country:US
Practice Address - Phone:715-550-6279
Practice Address - Fax:715-487-5638
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI106365163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4236437Medicaid
WI4058297Medicaid
WI5453633Medicaid