Basic Information
| Provider Information | |||||||||
| NPI: | 1164062345 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENCOE | ||||||||
| FirstName: | SARA | ||||||||
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| Credential: | DNP, CPNP-PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26000 W LUGONIA AVE APT 2311 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923745105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052808511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5904 HOLLY AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871132472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052982505 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2020 | ||||||||
| LastUpdateDate: | 07/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 95014132 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 62258 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.