Healthcare Provider Details

I. General information

NPI: 1225966989
Provider Name (Legal Business Name): TAMARA BENNETT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 ROOSEVELT AVE
GRANTS NM
87020
US

IV. Provider business mailing address

PO BOX 8
GRANTS NM
87020-0008
US

V. Phone/Fax

Practice location:
  • Phone: 505-285-2772
  • Fax: 505-285-2633
Mailing address:
  • Phone: 505-285-2772
  • Fax: 505-285-2633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR86652
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: