Provider Demographics
NPI:1699242065
Name:BENNETT, ELIZABETH EMILY (NP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:EMILY
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N FAIRMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-1614
Mailing Address - Country:US
Mailing Address - Phone:209-712-6531
Mailing Address - Fax:
Practice Address - Street 1:975 S FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5118
Practice Address - Country:US
Practice Address - Phone:209-333-3135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA812638163W00000X
CANP95010098363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP95010098OtherCALIFORNIA BOARD OF REGISTERED NURSING