Provider Demographics
NPI:1295381465
Name:BENJAMIN, KIZZIE NIVIA
Entity Type:Individual
Prefix:
First Name:KIZZIE
Middle Name:NIVIA
Last Name:BENJAMIN
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 1:5001 ALUTHRA WAY APT 1532
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-2325
Mailing Address - Country:US
Mailing Address - Phone:772-519-3333
Mailing Address - Fax:
Practice Address - Street 1:5001 ALUTHRA WAY APT 1532
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-2325
Practice Address - Country:US
Practice Address - Phone:772-519-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP19000060812343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)