Provider Demographics
NPI:1114441987
Name:BENSON, DARLENE
Entity Type:Individual
Prefix:
First Name:DARLENE
Middle Name:
Last Name:BENSON
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 1:22383 NEBISH RD NE
Mailing Address - Street 2:
Mailing Address - City:BLACKDUCK
Mailing Address - State:MN
Mailing Address - Zip Code:56630-5138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22383 NEBISH RD NE
Practice Address - Street 2:
Practice Address - City:BLACKDUCK
Practice Address - State:MN
Practice Address - Zip Code:56630-5138
Practice Address - Country:US
Practice Address - Phone:218-835-4525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-02
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No177F00000XOther Service ProvidersLodging
Provider Identifiers
StateIdentifier IDID TypeIssuer
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