Provider Demographics
NPI:1366599102
Name:BENTON, VICKI LOU (CRNA)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:LOU
Last Name:BENTON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6527 CARRIZO FALL CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-6245
Mailing Address - Country:US
Mailing Address - Phone:713-896-4535
Mailing Address - Fax:
Practice Address - Street 1:6527 CARRIZO FALL CT
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77041-6245
Practice Address - Country:US
Practice Address - Phone:713-896-4535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22598367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137821812Medicaid
TX430027383OtherRAILROAD MEDICARE
88597COtherTX-BLUE SHIELD
TX87033HMedicare PIN
TX137821812Medicaid