Provider Demographics
NPI:1386968899
Name:BENEDETTO, LISA M (CNM)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:BENEDETTO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 INDIAN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1331
Mailing Address - Country:US
Mailing Address - Phone:607-379-9606
Mailing Address - Fax:607-821-4374
Practice Address - Street 1:132 INDIAN CREEK RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1331
Practice Address - Country:US
Practice Address - Phone:607-379-9606
Practice Address - Fax:607-821-4374
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO171868363L00000X
CO13010367A00000X
NYF00149-1367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO26371243Medicaid