Provider Demographics
NPI:1073130167
Name:BENNETT, JUDANA SANDRA
Entity Type:Individual
Prefix:
First Name:JUDANA
Middle Name:SANDRA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 SUMNER ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-3396
Mailing Address - Country:US
Mailing Address - Phone:781-222-5530
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-643-8281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MARN2278761363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program