MEDICARE: DEMETRA BENNETT NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	ARNP9164847	FL
2	363L00000X	Nurse Practitioner	9164847	FL
3	363LF0000X	Family Nurse Practitioner	APRN9164847	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184676025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEMETRA BENNETT NP

Provider Business Mailing Address
First Line	:	3376 FIDDLE LEAF WAY
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33811-3001
Country	:	US
Telephone Number	:	863-602-8174
Fax Number	:

Provider Business Practice Location Address
First Line	:	930 MARCUM RD STE 5
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33809-4308
Country	:	US
Telephone Number	:	863-940-4886
Fax Number	:	863-816-5769

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	09/09/2020

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Directions to “ DEMETRA BENNETT NP” Practice Location

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