Provider Demographics
NPI:1215681515
Name:BENTON, KIMBERLY ANN
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:BENTON
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 1:67 HILLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BIG FLATS
Mailing Address - State:NY
Mailing Address - Zip Code:14814-7954
Mailing Address - Country:US
Mailing Address - Phone:607-425-1900
Mailing Address - Fax:
Practice Address - Street 1:4104 VESTAL RD STE 101
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-3500
Practice Address - Country:US
Practice Address - Phone:607-235-3980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261936031174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist