Provider Demographics
NPI:1144203407
Name:BENNETT, DIANA I
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:I
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 1:21930 STEWART RD
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-1110
Mailing Address - Country:US
Mailing Address - Phone:718-464-5364
Mailing Address - Fax:718-464-5364
Practice Address - Street 1:1030 SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-6100
Practice Address - Country:US
Practice Address - Phone:917-792-7600
Practice Address - Fax:917-792-7603
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0101-0407-7314-645183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0101-0407-7314-645OtherPHARMACY TECHNICIAN