Provider Demographics
NPI:1720513682
Name:BENALLY, JENNIFER MARIE (NP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:BENALLY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4721
Mailing Address - Country:US
Mailing Address - Phone:208-358-6917
Mailing Address - Fax:
Practice Address - Street 1:418 MADISON ST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4721
Practice Address - Country:US
Practice Address - Phone:208-358-6917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID55167363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily