Provider Demographics
NPI:1063794238
Name:BENNETTE, GLORY A (ARNP)
Entity type:Individual
Prefix:
First Name:GLORY
Middle Name:A
Last Name:BENNETTE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:GLORY
Other - Middle Name:A
Other - Last Name:COFFEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3466 N HARBOR CITY BLVD
Mailing Address - Street 2:CREDENTIALING
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-5713
Mailing Address - Country:US
Mailing Address - Phone:321-725-4505
Mailing Address - Fax:321-409-8932
Practice Address - Street 1:1223 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-725-4505
Practice Address - Fax:321-409-8932
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3410972363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily