Provider Demographics
NPI:1205569316
Name:BENSON, MICHELLE (CN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BENSON
Suffix:
Gender:F
Credentials:CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 17TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98516-3806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2116 CATON WAY SW STE 102
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-1176
Practice Address - Country:US
Practice Address - Phone:360-915-2151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA133N00000X
WANU61327590133NN1002X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education