Healthcare Provider Details

I. General information

NPI: 1548850134
Provider Name (Legal Business Name): MARIE ELIANTHE BENTZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 10/11/2021
Certification Date: 10/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5722 E STILLWATER AVE UNIT 8
ORANGE CA
92869-3187
US

IV. Provider business mailing address

5722 E STILLWATER AVE UNIT 8
ORANGE CA
92869-3187
US

V. Phone/Fax

Practice location:
  • Phone: 714-465-0875
  • Fax:
Mailing address:
  • Phone: 714-465-0875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number261026
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number95013446
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: