Provider Demographics
NPI:1952318339
Name:BENNETT, DEIRDRE L (NP, CNM)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:L
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3520
Mailing Address - Country:US
Mailing Address - Phone:207-767-2315
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:MAINE MEDICAL CENTER - INTERNAL MEDICINE CLINIC
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-2911
Practice Address - Fax:207-662-6308
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP81541363LF0000X
MECNM82024367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME001498101Medicare PIN