1912334038 NPI number — MRS. HEATHER LYNN BENTON YOUNG AU.D.

Table of content: (NPI 1750966818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912334038 NPI number — MRS. HEATHER LYNN BENTON YOUNG AU.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENTON YOUNG
Provider First Name:
HEATHER
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
AU.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BENTON
Provider Other First Name:
HEATHER
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
AU.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912334038
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
621 EAST MATTHEWS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-932-6799
Provider Business Mailing Address Fax Number:
870-932-8423

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 EAST MATTHEWS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-932-6799
Provider Business Practice Location Address Fax Number:
870-932-0265
Provider Enumeration Date:
10/03/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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