Healthcare Provider Details

I. General information

NPI: 1710959234
Provider Name (Legal Business Name): ELIZABETH ANN BENNETT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH ANN BENNETT-HAGUE

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 11/07/2021
Certification Date: 11/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9159 BLOOM CT
BURKE VA
22015-1643
US

IV. Provider business mailing address

9159 BLOOM CT
BURKE VA
22015-1643
US

V. Phone/Fax

Practice location:
  • Phone: 571-749-8420
  • Fax: 855-955-0445
Mailing address:
  • Phone: 571-749-8420
  • Fax: 855-955-0445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101236782
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: