Provider Demographics
NPI:1144830563
Name:BENGA, KAITLIN ANNE
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:ANNE
Last Name:BENGA
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 1:3060 N RIDGECREST UNIT 106
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-1087
Mailing Address - Country:US
Mailing Address - Phone:480-433-0969
Mailing Address - Fax:
Practice Address - Street 1:3060 N RIDGECREST UNIT 106
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-1087
Practice Address - Country:US
Practice Address - Phone:480-433-0969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-01
Last Update Date:2020-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program