Provider Demographics
NPI:1285243444
Name:BENNETT, TRACY TRAVINA (RN)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:TRAVINA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 HARVARD AVE UNIT 1736
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-7180
Mailing Address - Country:US
Mailing Address - Phone:909-322-2081
Mailing Address - Fax:
Practice Address - Street 1:10762 WILSON AVE
Practice Address - Street 2:
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91737-2436
Practice Address - Country:US
Practice Address - Phone:909-322-2081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA511336163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator