Provider Demographics
NPI:1346613320
Name:BERNABE-BENTIVOGLIO, JESSICA (CNM)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BERNABE-BENTIVOGLIO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 HALL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4657
Mailing Address - Country:US
Mailing Address - Phone:757-514-4700
Mailing Address - Fax:757-514-4873
Practice Address - Street 1:135 HALL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4657
Practice Address - Country:US
Practice Address - Phone:757-514-4700
Practice Address - Fax:757-514-4873
Is Sole Proprietor?:No
Enumeration Date:2015-11-12
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACNM2740367A00000X
VA0024172936363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner