Provider Demographics
NPI:1699289629
Name:BENCITO, NICOLE SHERI
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:SHERI
Last Name:BENCITO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7212 ORANGETHORPE AVE STE 9A
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-4668
Mailing Address - Country:US
Mailing Address - Phone:714-503-6550
Mailing Address - Fax:
Practice Address - Street 1:7212 ORANGETHORPE AVE STE 9A
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621
Practice Address - Country:US
Practice Address - Phone:714-503-6550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95043640163W00000X
CA95010939363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse