Provider Demographics
NPI:1578280376
Name:BENNER, EMILY ANNE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ANNE
Last Name:BENNER
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 1:9020 W LONE CACTUS DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-2469
Mailing Address - Country:US
Mailing Address - Phone:480-578-1867
Mailing Address - Fax:
Practice Address - Street 1:9305 W THOMAS RD STE 155
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3360
Practice Address - Country:US
Practice Address - Phone:480-573-7922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-21
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN199542163W00000X
AZ300203363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ203517Medicaid