Provider Demographics
NPI:1366731739
Name:BENNETT, HOLLY SUE (RN, BSN)
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:SUE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:MRS
Other - First Name:HOLLY
Other - Middle Name:SUE
Other - Last Name:MATA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2730 E FLOWER ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7461
Mailing Address - Country:US
Mailing Address - Phone:928-925-5917
Mailing Address - Fax:
Practice Address - Street 1:2730 E FLOWER ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7461
Practice Address - Country:US
Practice Address - Phone:928-925-5917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATLRN035206163WR0400X
AZRN147845163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WR0400XNursing Service ProvidersRegistered NurseRehabilitation