Provider Demographics
NPI:1992096275
Name:BENTON, WENDY DAWN
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:DAWN
Last Name:BENTON
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 1:122 17TH COURT NE
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:AL
Mailing Address - Zip Code:35555
Mailing Address - Country:US
Mailing Address - Phone:205-932-3900
Mailing Address - Fax:205-932-3941
Practice Address - Street 1:122 17TH COURT NE
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:AL
Practice Address - Zip Code:35555
Practice Address - Country:US
Practice Address - Phone:205-932-3900
Practice Address - Fax:205-932-3941
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-079781363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily