Provider Demographics
NPI:1609327337
Name:BENAVIDEZ, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:BENAVIDEZ
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:PO BOX 742325
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2325
Mailing Address - Country:US
Mailing Address - Phone:904-327-4466
Mailing Address - Fax:
Practice Address - Street 1:1431 ORANGE CAMP RD
Practice Address - Street 2:SUITE 118/119
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-7768
Practice Address - Country:US
Practice Address - Phone:386-740-4054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9336296363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily