Provider Demographics
NPI:1922783778
Name:BENEDICT, NIKKI LEE (SRNA)
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:LEE
Last Name:BENEDICT
Suffix:
Gender:M
Credentials:SRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BOGIE DR
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3741
Mailing Address - Country:US
Mailing Address - Phone:352-277-6625
Mailing Address - Fax:
Practice Address - Street 1:301 BOGIE DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3741
Practice Address - Country:US
Practice Address - Phone:352-277-6625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program