Provider Demographics
NPI:1528840444
Name:BENTON, ANTONIA ANGELINE (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:ANTONIA
Middle Name:ANGELINE
Last Name:BENTON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 N BRIARWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-3827
Mailing Address - Country:US
Mailing Address - Phone:405-487-6887
Mailing Address - Fax:
Practice Address - Street 1:3125 N BRIARWOOD AVE
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-3827
Practice Address - Country:US
Practice Address - Phone:405-487-6887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0099746163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice