Provider Demographics
NPI:1699259580
Name:DIBENEDETTO, KEITH (CRNP)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:DIBENEDETTO
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11121 YORK RD
Mailing Address - Street 2:
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21030-2006
Mailing Address - Country:US
Mailing Address - Phone:410-628-2026
Mailing Address - Fax:410-667-6834
Practice Address - Street 1:11121 YORK RD
Practice Address - Street 2:
Practice Address - City:HUNT VALLEY
Practice Address - State:MD
Practice Address - Zip Code:21030-2006
Practice Address - Country:US
Practice Address - Phone:410-628-2026
Practice Address - Fax:410-667-6834
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR210044363LA2200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health