Provider Demographics
NPI:1467902114
Name:BENJAMIN, MYKALA
Entity Type:Individual
Prefix:
First Name:MYKALA
Middle Name:
Last Name:BENJAMIN
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 1:25718 130TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-7991
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25718 130TH AVE SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7991
Practice Address - Country:US
Practice Address - Phone:206-280-4346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer