Provider Demographics
NPI:1144470493
Name:BENNION, BEVERLY PAIGE
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:PAIGE
Last Name:BENNION
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 1:2055 GARRETT WAY
Mailing Address - Street 2:STE 1
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5100
Mailing Address - Country:US
Mailing Address - Phone:208-236-1600
Mailing Address - Fax:208-236-6695
Practice Address - Street 1:4980 W STATE ST STE A
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-3326
Practice Address - Country:US
Practice Address - Phone:208-639-1649
Practice Address - Fax:208-639-0813
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372500000X
ID372600000X, 3747P1801X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1144470493Medicaid