Provider Demographics
NPI:1962874446
Name:BENNETT, DANICA (PA)
Entity type:Individual
Prefix:
First Name:DANICA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1492 S MILL AVE
Mailing Address - Street 2:#113
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-5652
Mailing Address - Country:US
Mailing Address - Phone:480-354-5900
Mailing Address - Fax:
Practice Address - Street 1:1492 S MILL AVE
Practice Address - Street 2:#113
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-5652
Practice Address - Country:US
Practice Address - Phone:480-354-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6256363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant