Healthcare Provider Details

I. General information

NPI: 1275893190
Provider Name (Legal Business Name): SIMONE BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 08/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 SAINT GERMAIN ST APT 3
BOSTON MA
02115-3241
US

IV. Provider business mailing address

7 FLORENCE ST APT 5
CAMBRIDGE MA
02139-4641
US

V. Phone/Fax

Practice location:
  • Phone: 206-303-9361
  • Fax:
Mailing address:
  • Phone: 206-303-9361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number258453
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: