Healthcare Provider Details

I. General information

NPI: 1699242065
Provider Name (Legal Business Name): ELIZABETH EMILY BENNETT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 S FAIRMONT AVE
LODI CA
95240-5118
US

IV. Provider business mailing address

500 N FAIRMONT AVE
LODI CA
95240-1614
US

V. Phone/Fax

Practice location:
  • Phone: 209-333-3135
  • Fax:
Mailing address:
  • Phone: 209-712-6531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95010098
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number812638
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: