Provider Demographics
NPI:1538391875
Name:BENSON, ETOSHIA RENE (APRN-C)
Entity type:Individual
Prefix:MS
First Name:ETOSHIA
Middle Name:RENE
Last Name:BENSON
Suffix:
Gender:F
Credentials:APRN-C
Other - Prefix:
Other - First Name:ETOSHIA
Other - Middle Name:RENE
Other - Last Name:ROUSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN-C
Mailing Address - Street 1:15 GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-3228
Mailing Address - Country:US
Mailing Address - Phone:864-423-8722
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:800-458-5653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3983363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1535OtherMCD#
SCNP1535Medicaid
SCAA4523Medicare UPIN