MEDICARE: MS. JUDITH A BENNETT RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	164540	WI

General Provider Information

NPI Number	:	1720352206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JUDITH A BENNETT RN

Provider Business Mailing Address
First Line	:	5213 MANITOWOC PKWY
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53705-4708
Country	:	US
Telephone Number	:	608-467-2802
Fax Number	:	608-468-2802

Provider Business Practice Location Address
First Line	:	5213 MANITOWOC PKWY
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53705-4708
Country	:	US
Telephone Number	:	608-467-2802
Fax Number	:	608-468-2802

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2012
Last Update Date	:	03/01/2012

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