Provider Demographics
NPI:1417085697
Name:IDA WALLACE BENNETT FAMILY HEALTH CORPORATION
Entity Type:Organization
Organization Name:IDA WALLACE BENNETT FAMILY HEALTH CORPORATION
Other - Org Name:IDA WALLACE BENNETT FAMILY CORPORATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:V
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:561-900-6737
Mailing Address - Street 1:331 N DEERFIELD AVENUE
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-2028
Mailing Address - Country:US
Mailing Address - Phone:561-900-6737
Mailing Address - Fax:954-422-1726
Practice Address - Street 1:331 N DEERFIELD AVE
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-2028
Practice Address - Country:US
Practice Address - Phone:561-900-6737
Practice Address - Fax:954-422-1726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QH0100X
FLARNP2155102363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBCBSFLOtherPTAN AK407