Provider Demographics
NPI:1629785399
Name:BENINI, TAZHARAE
Entity Type:Individual
Prefix:
First Name:TAZHARAE
Middle Name:
Last Name:BENINI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAZHARAE
Other - Middle Name:
Other - Last Name:BENINI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:117 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:KERSEY
Mailing Address - State:PA
Mailing Address - Zip Code:15846-9253
Mailing Address - Country:US
Mailing Address - Phone:814-594-8930
Mailing Address - Fax:
Practice Address - Street 1:117 HICKORY ST
Practice Address - Street 2:
Practice Address - City:KERSEY
Practice Address - State:PA
Practice Address - Zip Code:15846-9253
Practice Address - Country:US
Practice Address - Phone:814-594-8930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX5748133V00000X
MN4846133V00000X
SC2521133V00000X
PADN006266133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered