Provider Demographics
NPI:1699811943
Name:BENAVIDES, NICOLE S (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:S
Last Name:BENAVIDES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:S
Other - Last Name:PAUDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 SW H K DODGEN LOOP
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-1814
Practice Address - Country:US
Practice Address - Phone:254-935-4000
Practice Address - Fax:254-935-4111
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP115546367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX185590003Medicaid
TX185590004OtherCSHCN
TXB112417Medicare PIN