Provider Demographics
NPI:1871735977
Name:BENTON, MISTI G (NP)
Entity type:Individual
Prefix:MRS
First Name:MISTI
Middle Name:G
Last Name:BENTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:275 N HIGHWAY 16
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037-3000
Mailing Address - Country:US
Mailing Address - Phone:704-489-8401
Mailing Address - Fax:704-489-8404
Practice Address - Street 1:275 N HIGHWAY 16
Practice Address - Street 2:SUITE 103
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-3000
Practice Address - Country:US
Practice Address - Phone:704-489-8401
Practice Address - Fax:704-489-8404
Is Sole Proprietor?:No
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004116363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5950140Medicaid