Basic Information
| Provider Information | |||||||||
| NPI: | 1699242065 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | EMILY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 N FAIRMONT AVE | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952401614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097126531 | ||||||||
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| Practice Location | |||||||||
| Address1: | 975 S FAIRMONT AVE | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952405118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093333135 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2018 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 812638 | CA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | NP95010098 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NP95010098 | 01 | CA | CALIFORNIA BOARD OF REGISTERED NURSING | OTHER |