Healthcare Provider Details

I. General information

NPI: 1043360217
Provider Name (Legal Business Name): DONNA MARLANE BENNETT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DONNA MARLANE ORTEGON NP

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 S FAIRMONT AVE #8
LODI CA
95240-5113
US

IV. Provider business mailing address

523 OLIVE CT
LODI CA
95240-1044
US

V. Phone/Fax

Practice location:
  • Phone: 209-339-7633
  • Fax:
Mailing address:
  • Phone: 209-339-7633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number329221
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: