Provider Demographics
NPI:1215520101
Name:BENNETT, DAAIMAH JENNELL
Entity type:Individual
Prefix:
First Name:DAAIMAH
Middle Name:JENNELL
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-1959
Mailing Address - Country:US
Mailing Address - Phone:267-584-2322
Mailing Address - Fax:
Practice Address - Street 1:702 N 10TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-1959
Practice Address - Country:US
Practice Address - Phone:267-584-2322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA174200000X, 332U00000X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No174200000XOther Service ProvidersMeals
No332U00000XSuppliersHome Delivered Meals