Provider Demographics
NPI:1942440821
Name:BENALLY, TINA (AT)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BENALLY
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 N BUTLER AVE
Mailing Address - Street 2:STE 101& 102
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6429
Mailing Address - Country:US
Mailing Address - Phone:505-326-0064
Mailing Address - Fax:505-327-3995
Practice Address - Street 1:3501 N BUTLER AVE
Practice Address - Street 2:STE 101& 102
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6429
Practice Address - Country:US
Practice Address - Phone:505-326-0064
Practice Address - Fax:505-327-3995
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-04
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer