Provider Demographics
NPI:1639406754
Name:BENNETT, JOANN WYMAN (LAC)
Entity Type:Individual
Prefix:MS
First Name:JOANN
Middle Name:WYMAN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:372 NEVADA ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-6107
Mailing Address - Country:US
Mailing Address - Phone:415-377-1887
Mailing Address - Fax:415-585-0670
Practice Address - Street 1:605 CHENERY ST
Practice Address - Street 2:SUITE C
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94131-3033
Practice Address - Country:US
Practice Address - Phone:415-377-1887
Practice Address - Fax:415-585-0670
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 8984171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist