Basic Information
Provider Information | |||||||||
NPI: | 1801079462 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BENSON | ||||||||
FirstName: | DIEDRE | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4060 WESTOWN PWY | ||||||||
Address2: |   | ||||||||
City: | WEST DES MOINES | ||||||||
State: | IA | ||||||||
PostalCode: | 502661010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5152250769 | ||||||||
FaxNumber: | 5152250971 | ||||||||
Practice Location | |||||||||
Address1: | 4060 WESTOWN PKWY | ||||||||
Address2: |   | ||||||||
City: | WEST DES MOINES | ||||||||
State: | IA | ||||||||
PostalCode: | 502661010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5152250769 | ||||||||
FaxNumber: | 5152250971 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2007 | ||||||||
LastUpdateDate: | 08/13/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | S060913 | IA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.