Provider Demographics
NPI:1396858528
Name:BENSON, WYNELLE P
Entity Type:Individual
Prefix:
First Name:WYNELLE
Middle Name:P
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:PO BOX 429
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:MS
Mailing Address - Zip Code:38879-0429
Mailing Address - Country:US
Mailing Address - Phone:662-566-5593
Mailing Address - Fax:662-566-4419
Practice Address - Street 1:1423 PALMETTO RD
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:MS
Practice Address - Zip Code:38879
Practice Address - Country:US
Practice Address - Phone:662-566-5593
Practice Address - Fax:662-566-4419
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR558168363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0111505Medicaid
P65394Medicare UPIN