Provider Demographics
NPI:1558329862
Name:BENNETT, AMANDA DAWN (FNP-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:DAWN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 W REX ALLEN DR
Mailing Address - Street 2:
Mailing Address - City:WILLCOX
Mailing Address - State:AZ
Mailing Address - Zip Code:85643
Mailing Address - Country:US
Mailing Address - Phone:520-766-5000
Mailing Address - Fax:520-384-5001
Practice Address - Street 1:801 W REX ALLEN DR
Practice Address - Street 2:
Practice Address - City:WILLCOX
Practice Address - State:AZ
Practice Address - Zip Code:85643-1129
Practice Address - Country:US
Practice Address - Phone:520-766-5000
Practice Address - Fax:520-766-5001
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN109910/AP1963363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ868482Medicaid
AZQ21082Medicare UPIN
Z82704Medicare ID - Type Unspecified