Provider Demographics
NPI:1023655099
Name:SNELLGROVE, BENJAMIN (PMHNP)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:SNELLGROVE
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 N MULDOON RD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-6104
Mailing Address - Country:US
Mailing Address - Phone:888-353-7574
Mailing Address - Fax:
Practice Address - Street 1:1201 N MULDOON RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-6104
Practice Address - Country:US
Practice Address - Phone:888-353-7574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP144290363LP0808X
AK171269363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX407235701Medicaid