Healthcare Provider Details

I. General information

NPI: 1598139834
Provider Name (Legal Business Name): DONNA JOANNE BENNETT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2015
Last Update Date: 11/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5580 HUMMINGBIRD RD
BASCOM FL
32423-9136
US

IV. Provider business mailing address

5580 HUMMINGBIRD RD
BASCOM FL
32423-9136
US

V. Phone/Fax

Practice location:
  • Phone: 850-569-2627
  • Fax:
Mailing address:
  • Phone: 850-569-2627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN 9388168
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: