Provider Demographics
NPI:1184676025
Name:BENNETT, DEMETRA (NP)
Entity Type:Individual
Prefix:
First Name:DEMETRA
Middle Name:
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 1:3376 FIDDLE LEAF WAY
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33811-3001
Mailing Address - Country:US
Mailing Address - Phone:863-602-8174
Mailing Address - Fax:
Practice Address - Street 1:930 MARCUM RD STE 5
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-4308
Practice Address - Country:US
Practice Address - Phone:863-940-4886
Practice Address - Fax:863-816-5769
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9164847207P00000X
FL9164847363L00000X
FLAPRN9164847363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306599500Medicaid
FL306599500Medicaid
FLY057UAMedicare ID - Type Unspecified