Provider Demographics
NPI:1073844684
Name:BENTON, VANESSA NICHOLA (DC)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:NICHOLA
Last Name:BENTON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1791
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33568-1791
Mailing Address - Country:US
Mailing Address - Phone:813-922-2898
Mailing Address - Fax:813-699-9942
Practice Address - Street 1:500 VONDERBURG DR STE 105
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5968
Practice Address - Country:US
Practice Address - Phone:813-922-2898
Practice Address - Fax:813-699-9942
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10447111N00000X
GACHIR008602111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor