Provider Demographics
NPI:1295315539
Name:BENABURGER, KAYLA ROSE (LAC)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:ROSE
Last Name:BENABURGER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2785
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-0858
Mailing Address - Country:US
Mailing Address - Phone:631-742-8840
Mailing Address - Fax:631-880-7117
Practice Address - Street 1:248 MIDDLE COUNTRY RD STE 17
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-2583
Practice Address - Country:US
Practice Address - Phone:631-846-1661
Practice Address - Fax:631-880-7117
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006908171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist