Provider Demographics
NPI:1114781481
Name:BENTON, STEPHANIE ANN
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:BENTON
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 1:1157 E GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4985
Mailing Address - Country:US
Mailing Address - Phone:863-651-0109
Mailing Address - Fax:
Practice Address - Street 1:1157 E GROVE AVE
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4985
Practice Address - Country:US
Practice Address - Phone:863-651-0109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide