Provider Demographics
NPI:1881423275
Name:PRIESTLEY, BENITA LASHAE
Entity type:Individual
Prefix:
First Name:BENITA
Middle Name:LASHAE
Last Name:PRIESTLEY
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 1:1069 BROADWAY AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:CA
Mailing Address - Zip Code:93955-4995
Mailing Address - Country:US
Mailing Address - Phone:831-383-3562
Mailing Address - Fax:
Practice Address - Street 1:1069 BROADWAY AVE STE 201
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955-4995
Practice Address - Country:US
Practice Address - Phone:831-383-3562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS20974174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist