Provider Demographics
NPI:1558575076
Name:BENNETT, REBECCA LYNN (NP MS)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:LYNN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NP MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4512 MAX DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-3113
Mailing Address - Country:US
Mailing Address - Phone:619-563-3996
Mailing Address - Fax:
Practice Address - Street 1:3020 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4223
Practice Address - Country:US
Practice Address - Phone:858-576-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA376266363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics