Healthcare Provider Details

I. General information

NPI: 1306667944
Provider Name (Legal Business Name): ALEXANDRA RUBY BENNETT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 BARTON BLVD UNIT C-14
ROCKLEDGE FL
32955-2742
US

IV. Provider business mailing address

PO BOX 1137
MELBOURNE FL
32902-1137
US

V. Phone/Fax

Practice location:
  • Phone: 321-241-6800
  • Fax: 321-241-6890
Mailing address:
  • Phone: 321-952-9696
  • Fax: 321-952-7937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9119418
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: