Provider Demographics
NPI:1699286559
Name:BENASSOU, OTMAINE (PMHNP)
Entity type:Individual
Prefix:
First Name:OTMAINE
Middle Name:
Last Name:BENASSOU
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14350 HOOVER AVE APT 303
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2158
Mailing Address - Country:US
Mailing Address - Phone:347-579-8495
Mailing Address - Fax:
Practice Address - Street 1:669 CASTLETON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2028
Practice Address - Country:US
Practice Address - Phone:718-442-2225
Practice Address - Fax:718-442-2289
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF402232-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health