Provider Demographics
NPI:1952093353
Name:BENNER, KATELYN IRENE (EMT-B)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:IRENE
Last Name:BENNER
Suffix:
Gender:F
Credentials:EMT-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17045 DAPPLE GRAY RD
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:96022-9636
Mailing Address - Country:US
Mailing Address - Phone:530-737-7169
Mailing Address - Fax:
Practice Address - Street 1:875 PERIMETER DR
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83844-9803
Practice Address - Country:US
Practice Address - Phone:208-885-2182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist