Healthcare Provider Details

I. General information

NPI: 1740238724
Provider Name (Legal Business Name): DEANNA M BENNETT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

0610 TERRAPIN TRAIL UNIVERSITY OF MARYLAND
COLLEGE PARK MD
20741-0295
US

IV. Provider business mailing address

706 HOWARDS LOOP
ANNAPOLIS MD
21401-8740
US

V. Phone/Fax

Practice location:
  • Phone: 301-314-7137
  • Fax: 301-314-9439
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: