Provider Demographics
NPI:1487933545
Name:BENTON, LISA M (ARNP)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:BENTON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-6348
Mailing Address - Country:US
Mailing Address - Phone:509-249-1288
Mailing Address - Fax:509-249-6249
Practice Address - Street 1:611 N 39TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-6348
Practice Address - Country:US
Practice Address - Phone:509-249-1288
Practice Address - Fax:509-249-6249
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15974363LF0000X
WAAP60230744363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMB2445941OtherDEA WA