Provider Demographics
NPI:1679819437
Name:MIDDLETON-BENJAMIN, LADY-DIAESHA LATIESH (LPN)
Entity Type:Individual
Prefix:
First Name:LADY-DIAESHA
Middle Name:LATIESH
Last Name:MIDDLETON-BENJAMIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:DIAESHA
Other - Middle Name:LATIESH
Other - Last Name:BENJAMIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:7214 NE 155TH ST
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-4637
Mailing Address - Country:US
Mailing Address - Phone:206-617-4492
Mailing Address - Fax:
Practice Address - Street 1:7214 NE 155TH ST
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:WA
Practice Address - Zip Code:98028-4637
Practice Address - Country:US
Practice Address - Phone:206-617-4492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP00050451164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse