Healthcare Provider Details

I. General information

NPI: 1629037999
Provider Name (Legal Business Name): ALICIA MARIE BENNETT MS, ATC, CPFS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 11/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 LAMA ST.
LANAI CITY HI
96763-0630
US

IV. Provider business mailing address

340 LAMA ST.
LANAI CITY HI
96763-0630
US

V. Phone/Fax

Practice location:
  • Phone: 808-559-6435
  • Fax:
Mailing address:
  • Phone: 808-559-6435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: