Healthcare Provider Details

I. General information

NPI: 1003097205
Provider Name (Legal Business Name): DEBORAH BENNETT PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W 17TH ST
SANTA ANA CA
92706-2316
US

IV. Provider business mailing address

34461 CALLE PORTOLA
CAPISTRANO BEACH CA
92624-1055
US

V. Phone/Fax

Practice location:
  • Phone: 714-834-7763
  • Fax:
Mailing address:
  • Phone: 949-248-2206
  • Fax: 949-248-2218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number268922
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: