Provider Demographics
NPI:1235883430
Name:BENAVIDEZ, JACQUELINE NICOLE (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:BENAVIDEZ
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:NICOLE
Other - Last Name:LUCERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1620 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1008
Mailing Address - Country:US
Mailing Address - Phone:801-822-2234
Mailing Address - Fax:
Practice Address - Street 1:6709 ACADEMY RD NE STE B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3363
Practice Address - Country:US
Practice Address - Phone:505-977-2135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM65250363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily