Healthcare Provider Details

I. General information

NPI: 1851326441
Provider Name (Legal Business Name): ELLEN W BENNIS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE ST 680 DULLES
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

3400 SPRUCE ST 680 DULLES
PHILADELPHIA PA
19104
US

V. Phone/Fax

Practice location:
  • Phone: 215-349-8310
  • Fax:
Mailing address:
  • Phone: 215-349-8310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN502498L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: