Provider Demographics
NPI:1568911865
Name:BENJAMIN, SHANNON MICHELLE (RN,WCC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:RN,WCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 E GLENHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-1394
Mailing Address - Country:US
Mailing Address - Phone:337-680-0001
Mailing Address - Fax:
Practice Address - Street 1:2519 PALMETO DR
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563-2926
Practice Address - Country:US
Practice Address - Phone:337-680-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN141609163W00000X
LA4260923163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WW0000XNursing Service ProvidersRegistered NurseWound Care