Provider Demographics
NPI:1154163004
Name:BENCOMO, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BENCOMO
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 1:6800 W 16TH DR APT 304
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-4454
Mailing Address - Country:US
Mailing Address - Phone:786-326-0703
Mailing Address - Fax:
Practice Address - Street 1:2150 W 76TH ST STE 117
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-1887
Practice Address - Country:US
Practice Address - Phone:786-636-6952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11033215363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner