Provider Demographics
NPI:1568259109
Name:BENJAMIN, MAKEBA LACHERYL
Entity type:Individual
Prefix:
First Name:MAKEBA
Middle Name:LACHERYL
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10310 VAUGHN DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95212-9344
Mailing Address - Country:US
Mailing Address - Phone:209-981-9551
Mailing Address - Fax:
Practice Address - Street 1:10310 VAUGHN DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95212-9344
Practice Address - Country:US
Practice Address - Phone:209-981-9551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95034214363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner