Provider Demographics
NPI:1447468863
Name:BENN, KIESHA NICOLE (MD, FACOG)
Entity type:Individual
Prefix:MS
First Name:KIESHA
Middle Name:NICOLE
Last Name:BENN
Suffix:
Gender:F
Credentials:MD, FACOG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3885 LITTLE BLUESTEM DR
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-8302
Mailing Address - Country:US
Mailing Address - Phone:917-826-1353
Mailing Address - Fax:
Practice Address - Street 1:1301 PLEASANT VALLEY RD STE 301
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-9774
Practice Address - Country:US
Practice Address - Phone:270-417-7720
Practice Address - Fax:270-417-7750
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY56679207VM0101X
CT051669207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1447468863Medicaid