Healthcare Provider Details

I. General information

NPI: 1346613320
Provider Name (Legal Business Name): JESSICA BERNABE-BENTIVOGLIO CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 07/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 HALL AVE SUITE A
SUFFOLK VA
23434-4657
US

IV. Provider business mailing address

135 HALL AVE SUITE A
SUFFOLK VA
23434-4657
US

V. Phone/Fax

Practice location:
  • Phone: 757-514-4700
  • Fax: 757-514-4873
Mailing address:
  • Phone: 757-514-4700
  • Fax: 757-514-4873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberCNM2740
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024172936
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: