Provider Demographics
NPI:1578685186
Name:BENNETT-WILSON, MARVA LOUISE (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:MARVA
Middle Name:LOUISE
Last Name:BENNETT-WILSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:MARVA
Other - Middle Name:LOUISE
Other - Last Name:DYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICENSED PRACTICAL N
Mailing Address - Street 1:7188 S US #1
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952
Mailing Address - Country:US
Mailing Address - Phone:772-301-1274
Mailing Address - Fax:772-301-1387
Practice Address - Street 1:7188 S US #1
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952
Practice Address - Country:US
Practice Address - Phone:772-301-1274
Practice Address - Fax:772-301-1387
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5157934164W00000X
FLRN9389778163W00000X, 251J00000X
251E00000X, 251F00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No163W00000XNursing Service ProvidersRegistered Nurse
No251E00000XAgenciesHome Health
No251F00000XAgenciesHome Infusion
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014818700Medicaid
FL019161900Medicaid