Healthcare Provider Details

I. General information

NPI: 1437482262
Provider Name (Legal Business Name): LUCKY BENNETT ND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 09/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 MOUNT VERNON AVE
ALEXANDRIA VA
22301-1313
US

IV. Provider business mailing address

2201 MOUNT VERNON AVE
ALEXANDRIA VA
22301-1313
US

V. Phone/Fax

Practice location:
  • Phone: 571-228-9718
  • Fax:
Mailing address:
  • Phone: 571-228-9718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNP-0012
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNT 60059890
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: