Provider Demographics
NPI:1922862796
Name:BENAVIDES, STEPHANIE MOULARD
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MOULARD
Last Name:BENAVIDES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5543
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71307-5543
Mailing Address - Country:US
Mailing Address - Phone:318-443-9339
Mailing Address - Fax:
Practice Address - Street 1:5920 COLISEUM BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3714
Practice Address - Country:US
Practice Address - Phone:318-443-9339
Practice Address - Fax:318-443-9116
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA234406363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health