Provider Demographics
NPI:1558082131
Name:BENOIT-WYLIE, DEREK J (MSN, RN)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:J
Last Name:BENOIT-WYLIE
Suffix:
Gender:M
Credentials:MSN, RN
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:BENOIT-WYLIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSN, RN
Mailing Address - Street 1:140 W 29TH ST # 355
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1002
Mailing Address - Country:US
Mailing Address - Phone:719-568-8080
Mailing Address - Fax:
Practice Address - Street 1:2132 DRIFTWOOD LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2723
Practice Address - Country:US
Practice Address - Phone:719-568-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1633865163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty