Basic Information
| Provider Information | |||||||||
| NPI: | 1316375413 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANBENEDEN | ||||||||
| FirstName: | INGRID | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PAAA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JIMENEZ | ||||||||
| OtherFirstName: | INGRID | ||||||||
| OtherMiddleName: | V | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3155 N POINT PKWY STE F100 | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300055495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706459181 | ||||||||
| FaxNumber: | 7706458455 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 JOHNSON FERRY RD | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706459181 | ||||||||
| FaxNumber: | 7706458455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2013 | ||||||||
| LastUpdateDate: | 02/10/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 007018 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.