Provider Demographics
NPI:1134701683
Name:BENFIELD, ODETTA PATRICIA
Entity type:Individual
Prefix:
First Name:ODETTA
Middle Name:PATRICIA
Last Name:BENFIELD
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 1:1529 AGATE ST
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-2803
Mailing Address - Country:US
Mailing Address - Phone:631-338-2925
Mailing Address - Fax:
Practice Address - Street 1:1529 AGATE ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-2803
Practice Address - Country:US
Practice Address - Phone:631-338-2925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-24
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310986164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse