Provider Demographics
NPI:1245941509
Name:BENNY, SANDRA JEAN
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEAN
Last Name:BENNY
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 1:190 CARY PL
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-5028
Mailing Address - Country:US
Mailing Address - Phone:805-610-9012
Mailing Address - Fax:
Practice Address - Street 1:115 E FESLER ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4404
Practice Address - Country:US
Practice Address - Phone:805-922-6597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91165163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)