Provider Demographics
NPI:1669101267
Name:BENISON, SHONTAE S
Entity type:Individual
Prefix:
First Name:SHONTAE
Middle Name:S
Last Name:BENISON
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 1:13212 TERMINAL AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44135-4814
Mailing Address - Country:US
Mailing Address - Phone:440-625-6300
Mailing Address - Fax:440-625-6301
Practice Address - Street 1:1100 W BAGLEY RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-2925
Practice Address - Country:US
Practice Address - Phone:440-625-6300
Practice Address - Fax:440-625-6301
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2022-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH246YR1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246YR1600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health InformationRegistered Record Administrator