Provider Demographics
NPI:1467764779
Name:BENEFIELD, AMY E
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:E
Last Name:BENEFIELD
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-261-3606
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:3017 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-1833
Practice Address - Country:US
Practice Address - Phone:228-831-0050
Practice Address - Fax:228-831-1121
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR863937367500000X
AL1-125754367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02582807Medicaid
MS9963845OtherAETNA
MS1540792OtherCIGNA
MS3476658OtherUNITED HEALTHCARE
MS302I431547Medicare PIN