Provider Demographics
NPI:1740934405
Name:BENITEZ, FERNANDO
Entity type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:BENITEZ
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 1:2121 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3413
Mailing Address - Country:US
Mailing Address - Phone:651-338-8247
Mailing Address - Fax:
Practice Address - Street 1:2121 1ST ST
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3413
Practice Address - Country:US
Practice Address - Phone:651-338-8247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker