Provider Demographics
NPI:1326600875
Name:SMITH, BENNETT
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BENNETT
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2100 CAPITOL AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5721
Mailing Address - Country:US
Mailing Address - Phone:916-442-4985
Mailing Address - Fax:
Practice Address - Street 1:2100 CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5721
Practice Address - Country:US
Practice Address - Phone:916-442-4985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA688466164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse