=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174872469
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SIMONE NATASHA BENTLEY APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2012
-----------------------------------------------------
Last Update Date | 11/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9900 BREN RD E MAIL ROUTE MN 008-B213
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55343-9664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-967-2723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 S MAIN ST STE 1300
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38103-5513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-422-7617
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 5151
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------