Provider Demographics
NPI:1063491538
Name:BENNETT, SANDRA K (NP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:K
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 1:11001 N BLACK CANYON HWY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4757
Mailing Address - Country:US
Mailing Address - Phone:602-371-2964
Mailing Address - Fax:
Practice Address - Street 1:11001 N BLACK CANYON HWY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4757
Practice Address - Country:US
Practice Address - Phone:602-371-2964
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN056710363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ916124Medicare ID - Type Unspecified
AZS83626Medicare UPIN
AZ101846Medicare ID - Type Unspecified