Provider Demographics
NPI:1962029827
Name:BOCANEGRA, BENITA C
Entity type:Individual
Prefix:
First Name:BENITA
Middle Name:C
Last Name:BOCANEGRA
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 1:1424 OLD STATION LOOP
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:VA
Mailing Address - Zip Code:24101-3600
Mailing Address - Country:US
Mailing Address - Phone:540-765-7718
Mailing Address - Fax:
Practice Address - Street 1:1424 OLD STATION LOOP
Practice Address - Street 2:
Practice Address - City:HARDY
Practice Address - State:VA
Practice Address - Zip Code:24101-3600
Practice Address - Country:US
Practice Address - Phone:540-765-7718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024179521363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care