Provider Demographics
NPI:1063742344
Name:RICE, BENJAMIN P (FNP-BC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:P
Last Name:RICE
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4607 MACCORKLE AVE SW STE 406
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1364
Mailing Address - Country:US
Mailing Address - Phone:304-766-4342
Mailing Address - Fax:304-766-3541
Practice Address - Street 1:4607 MACCORKLE AVE SW STE 406
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1364
Practice Address - Country:US
Practice Address - Phone:304-766-4342
Practice Address - Fax:304-766-3541
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV52497363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003017OtherKVGA GROUP MEDICAID