Basic Information
| Provider Information | |||||||||
| NPI: | 1902176837 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT-ROWE | ||||||||
| FirstName: | NEDRA | ||||||||
| MiddleName: | DEON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8354 CANDLEWOOD COVE TRL | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322448900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047719758 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11565 HARTS RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322183777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047511834 | ||||||||
| FaxNumber: | 9047513731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2012 | ||||||||
| LastUpdateDate: | 01/10/2012 | ||||||||
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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 | 225100000X | PT20561 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.