Provider Demographics
NPI:1174053706
Name:BENZONI, NICOLE S (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:S
Last Name:BENZONI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 NW MYHRE RD
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7663
Mailing Address - Country:US
Mailing Address - Phone:360-744-6525
Mailing Address - Fax:360-744-8530
Practice Address - Street 1:1800 NW MYHRE RD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7663
Practice Address - Country:US
Practice Address - Phone:360-744-6525
Practice Address - Fax:360-744-8530
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020039005207P00000X, 207RC0200X
MO2020013242207RC0200X
WAMD61251859207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2211804Medicaid