Basic Information
| Provider Information | |||||||||
| NPI: | 1104248129 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENKNER | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BLVD STE 3D | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480333849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221865 | ||||||||
| FaxNumber: | 9475220307 | ||||||||
| Practice Location | |||||||||
| Address1: | 44201 DEQUINDRE RD STE EC | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480851117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482593088 | ||||||||
| FaxNumber: | 2489646133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2014 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 4704386315 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0111452 | 05 | OH | MEDICAID |