Provider Demographics
NPI:1831100692
Name:BENNETT, BETTY A (MN ARNP)
Entity Type:Individual
Prefix:MRS
First Name:BETTY
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MN ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20696 BOND RD NE
Mailing Address - Street 2:STE 110
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370
Mailing Address - Country:US
Mailing Address - Phone:360-697-5500
Mailing Address - Fax:360-697-5522
Practice Address - Street 1:20696 BOND RD NE
Practice Address - Street 2:STE 110
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370
Practice Address - Country:US
Practice Address - Phone:360-697-5500
Practice Address - Fax:360-697-5522
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30002493363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9641366Medicaid
WA9641366Medicaid
255760Medicare UPIN
WA8858879Medicare ID - Type Unspecified