Provider Demographics
NPI:1467458588
Name:BENTON, JEAN LAZENBY (FNP-C)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:LAZENBY
Last Name:BENTON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:BEATRICE
Other - Middle Name:LAZENBY
Other - Last Name:DENTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-C
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1904
Mailing Address - Fax:704-867-2134
Practice Address - Street 1:111 E THIRD AVE
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-4343
Practice Address - Country:US
Practice Address - Phone:704-874-3300
Practice Address - Fax:704-874-0065
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200956363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000985Medicaid
NC7000985Medicaid
P56544Medicare UPIN