Healthcare Provider Details

I. General information

NPI: 1821440694
Provider Name (Legal Business Name): JUSTINE F FAGER-BENNETT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2016
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MEMORIAL MEDICAL PKWY
DAYTONA BEACH FL
32117-5167
US

IV. Provider business mailing address

2555 S ATLANTIC AVE APT 1604
DAYTONA BEACH SHORES FL
32118-5537
US

V. Phone/Fax

Practice location:
  • Phone: 386-231-6000
  • Fax: 317-705-5047
Mailing address:
  • Phone: 386-566-7431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN3198542
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: