Provider Demographics
NPI:1619448578
Name:BENKEN, JOAN MARCY
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:MARCY
Last Name:BENKEN
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 1:250 HOBART RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-1510
Mailing Address - Country:US
Mailing Address - Phone:631-765-5619
Mailing Address - Fax:
Practice Address - Street 1:250 HOBART RD
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-1510
Practice Address - Country:US
Practice Address - Phone:631-765-5619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF420374363LW0102X
NY377979163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
11323OtherLCCE
NYF420374OtherNURSE PRACTITIONER IN WOMEN'S HEALTH
L-13471OtherIBCLC
NY377979OtherRN