Provider Demographics
NPI:1194418988
Name:BENENATI, KATHERINE ELIZABETH (AGACNP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELIZABETH
Last Name:BENENATI
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ELIZABETH
Other - Last Name:MCCORMACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 MEMORIAL DR STE 106
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6723
Mailing Address - Country:US
Mailing Address - Phone:618-433-1861
Mailing Address - Fax:618-433-9274
Practice Address - Street 1:300 MEDICAL PLZ STE 150
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-1483
Practice Address - Country:US
Practice Address - Phone:636-625-2662
Practice Address - Fax:636-625-1644
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023017608363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily