Provider Demographics
NPI:1104171313
Name:HERBERT, BENJAMIN DAVID (LPN)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:DAVID
Last Name:HERBERT
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 SOMERTON AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1624
Mailing Address - Country:US
Mailing Address - Phone:716-913-4753
Mailing Address - Fax:
Practice Address - Street 1:46 SOMERTON AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1624
Practice Address - Country:US
Practice Address - Phone:716-913-4753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-14
Last Update Date:2012-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310171-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse