Healthcare Provider Details

I. General information

NPI: 1952423634
Provider Name (Legal Business Name): DEBRA ANN BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747-52ND ST
OAKLAND CA
94609
US

IV. Provider business mailing address

8309 MONTIGLIO CT
VALLEJO CA
94591-8565
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-3006
  • Fax: 510-601-3912
Mailing address:
  • Phone: 510-428-3885
  • Fax: 510-601-3912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number391900
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: