Provider Demographics
NPI:1134878879
Name:BENTON, BERNESTINE C
Entity type:Individual
Prefix:
First Name:BERNESTINE
Middle Name:C
Last Name:BENTON
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 1:105 FUNDY BAY
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94502-7926
Mailing Address - Country:US
Mailing Address - Phone:510-612-9605
Mailing Address - Fax:
Practice Address - Street 1:105 FUNDY BAY
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94502-7926
Practice Address - Country:US
Practice Address - Phone:510-612-9605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA