Healthcare Provider Details

I. General information

NPI: 1689083750
Provider Name (Legal Business Name): BISONA YEBA BENNETT DNP, APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BISONA YEBA TITALANGA DNP, APRN, FNP-C

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 KINGSLEY LAKE DR STE 703
ST AUGUSTINE FL
32092-3045
US

IV. Provider business mailing address

305 KINGSLEY LAKE DR STE 703
ST AUGUSTINE FL
32092-3045
US

V. Phone/Fax

Practice location:
  • Phone: 904-800-4003
  • Fax: 904-800-5003
Mailing address:
  • Phone: 904-800-4003
  • Fax: 904-800-5003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11013652
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: