Provider Demographics
NPI:1447244041
Name:BENOIT, DEBRA EASLEY (MSN)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:EASLEY
Last Name:BENOIT
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:CAROL
Other - Last Name:SIVERTSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSN
Mailing Address - Street 1:1113 RYEGATE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21286-1746
Mailing Address - Country:US
Mailing Address - Phone:410-296-8011
Mailing Address - Fax:
Practice Address - Street 1:920 2ND AVE S
Practice Address - Street 2:SUITE 400
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-3318
Practice Address - Country:US
Practice Address - Phone:612-225-1512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR075232363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD082NL177Medicare PIN
DC019240M72Medicare PIN