Healthcare Provider Details

I. General information

NPI: 1902217748
Provider Name (Legal Business Name): ALYSHA BENNETT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 11/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3377 RIVERBEND DR
SPRINGFIELD OR
97477-8803
US

IV. Provider business mailing address

1919 E THOMAS RD
PHOENIX AZ
85016-7710
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-8500
  • Fax: 541-222-6435
Mailing address:
  • Phone: 541-520-8116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD182796
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: