Healthcare Provider Details

I. General information

NPI: 1851256242
Provider Name (Legal Business Name): ELIZABETH BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1047B JOHN SIMS PKWY E
NICEVILLE FL
32578-2712
US

IV. Provider business mailing address

4485 TURNBERRY PL
NICEVILLE FL
32578-3824
US

V. Phone/Fax

Practice location:
  • Phone: 850-729-1068
  • Fax:
Mailing address:
  • Phone: 615-944-3146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number44158
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: