Provider Demographics
NPI:1427607308
Name:BENTON, CAEDORA MARYLOUISE (NP)
Entity Type:Individual
Prefix:MRS
First Name:CAEDORA
Middle Name:MARYLOUISE
Last Name:BENTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CAEDORA
Other - Middle Name:MARYLOUISE
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3125 POPLARWOOD CT STE 203
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-6445
Mailing Address - Country:US
Mailing Address - Phone:919-787-6131
Mailing Address - Fax:
Practice Address - Street 1:2101 GARNER RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-0114
Practice Address - Country:US
Practice Address - Phone:919-787-6131
Practice Address - Fax:919-571-2932
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC264004163W00000X
VA0024183725363LF0000X
NC5012193363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse