Healthcare Provider Details

I. General information

NPI: 1245969062
Provider Name (Legal Business Name): AMY KRISTINA BENNETT RN, NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6306 SEAMAN ST
SAN DIEGO CA
92120-2626
US

IV. Provider business mailing address

6306 SEAMAN ST
SAN DIEGO CA
92120-2626
US

V. Phone/Fax

Practice location:
  • Phone: 858-205-3306
  • Fax:
Mailing address:
  • Phone: 858-205-3306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11019
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number495091
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: