Provider Demographics
NPI:1922796077
Name:BENTON, LESA JOY (NP)
Entity Type:Individual
Prefix:
First Name:LESA
Middle Name:JOY
Last Name:BENTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7477 SE 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-8206
Mailing Address - Country:US
Mailing Address - Phone:503-572-4196
Mailing Address - Fax:
Practice Address - Street 1:7477 SE 52ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-8206
Practice Address - Country:US
Practice Address - Phone:503-572-4196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-26
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61415533363LA2200X, 363LG0600X
OR10007097363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health