Provider Demographics
NPI:1629382114
Name:BENJAMIN, ELIZABETH RATNAMALA (NURSE PRACTIONER)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:RATNAMALA
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:NURSE PRACTIONER
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:RATNAMALA
Other - Last Name:BENJAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACTIONER
Mailing Address - Street 1:3600 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-4116
Mailing Address - Country:US
Mailing Address - Phone:631-920-8500
Mailing Address - Fax:631-920-8501
Practice Address - Street 1:3600 ROUTE 112
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-4116
Practice Address - Country:US
Practice Address - Phone:631-920-8500
Practice Address - Fax:631-920-8501
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401255363LP0808X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health