Healthcare Provider Details

I. General information

NPI: 1487756243
Provider Name (Legal Business Name): HEIDI LEEA BENNETT P.A.-C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEIDI HULL

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 N CIRCLE DR STE 210
COLORADO SPRINGS CO
80909
US

IV. Provider business mailing address

PO BOX 4659
SAN LUIS OBISPO CA
93403-4659
US

V. Phone/Fax

Practice location:
  • Phone: 719-228-9440
  • Fax: 719-228-9061
Mailing address:
  • Phone: 805-544-7246
  • Fax: 805-782-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA0002477
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: