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General NPI Number Information
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NPI Number | 1417085697
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Entity Type | Organization
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Legal Business Name | IDA WALLACE BENNETT FAMILY HEALTH CORPORATION
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Dates
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Enumeration Date | 03/01/2007
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Last Update Date | 07/16/2013
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Provider Practice Location Address
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Address Line | 331 N DEERFIELD AVE
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City | DEERFIELD BEACH
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State | FL
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Zip | 33441-2028
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Country | US
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Telephone | 561-900-6737
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Fax | 954-422-1726
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Provider Business Mailing Address
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Address Line | 331 N DEERFIELD AVENUE
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City | DEERFIELD BEACH
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State | FL
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Zip | 33441-2028
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Country | US
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Telephone | 561-900-6737
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Fax | 954-422-1726
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Authorized Official
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Title or Position | PRESIDENT
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Name | PAMELA V JOHNSON
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Credential | ARNP
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Telephone | 561-900-6737
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | ARNP2155102
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License Number State | FL
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