Provider Demographics
NPI:1043360217
Name:BENNETT, DONNA MARLANE (FNP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MARLANE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:MARLANE
Other - Last Name:ORTEGON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:523 OLIVE CT
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-1044
Mailing Address - Country:US
Mailing Address - Phone:209-339-7633
Mailing Address - Fax:
Practice Address - Street 1:845 S FAIRMONT AVE
Practice Address - Street 2:#8
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5113
Practice Address - Country:US
Practice Address - Phone:209-339-7633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA329221363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health