Provider Demographics
NPI:1063089951
Name:BENJAMIN, KATRINA
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:BENJAMIN
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 1:8696 BELMOR LAKES DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7375
Mailing Address - Country:US
Mailing Address - Phone:901-849-6881
Mailing Address - Fax:
Practice Address - Street 1:8696 BELMOR LAKES DR
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-7375
Practice Address - Country:US
Practice Address - Phone:901-849-6881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1965133V00000X
MSD1257133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered