Healthcare Provider Details

I. General information

NPI: 1689649477
Provider Name (Legal Business Name): HEATHER BENNETT CRNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 02/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 N CENTRAL AVE SUITE 1600
PHOENIX AZ
85004-4527
US

IV. Provider business mailing address

PO BOX 34864
PHOENIX AZ
85067-4864
US

V. Phone/Fax

Practice location:
  • Phone: 602-262-8900
  • Fax: 602-445-4079
Mailing address:
  • Phone: 602-262-8900
  • Fax: 602-445-4079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberRN049561
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: