Provider Demographics
NPI:1770022873
Name:BENNETT, DEREK KEVIN X
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:KEVIN
Last Name:BENNETT
Suffix:X
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2547 W 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-1070
Mailing Address - Country:US
Mailing Address - Phone:248-961-1168
Mailing Address - Fax:
Practice Address - Street 1:2547 W 8 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-1070
Practice Address - Country:US
Practice Address - Phone:248-961-1168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704180735163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse