Provider Demographics
NPI:1790217685
Name:BENTON, TWOANDA (PHLEBOTOMIST)
Entity Type:Individual
Prefix:
First Name:TWOANDA
Middle Name:
Last Name:BENTON
Suffix:
Gender:F
Credentials:PHLEBOTOMIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6219 LENOX AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63133-2223
Mailing Address - Country:US
Mailing Address - Phone:314-348-3898
Mailing Address - Fax:
Practice Address - Street 1:6219 LENOX AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63133-2223
Practice Address - Country:US
Practice Address - Phone:314-348-3898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC001504059247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other