Provider Demographics
NPI:1275893190
Name:BENNETT, SIMONE
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:
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 1:7 FLORENCE ST APT 5
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4641
Mailing Address - Country:US
Mailing Address - Phone:206-303-9361
Mailing Address - Fax:
Practice Address - Street 1:48 SAINT GERMAIN ST APT 3
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-3241
Practice Address - Country:US
Practice Address - Phone:206-303-9361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA258453208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics