Provider Demographics
NPI:1427788009
Name:BENENSON, AMY ROSE (MSPAS, PA-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ROSE
Last Name:BENENSON
Suffix:
Gender:F
Credentials:MSPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 FIELDSTONE
Mailing Address - Street 2:
Mailing Address - City:LEDYARD
Mailing Address - State:CT
Mailing Address - Zip Code:06339-1250
Mailing Address - Country:US
Mailing Address - Phone:516-304-8956
Mailing Address - Fax:
Practice Address - Street 1:289 WINDHAM RD
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-3528
Practice Address - Country:US
Practice Address - Phone:860-343-0302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01468207QA0401X
CT5717363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPA01468Medicaid