Provider Demographics
NPI:1962463752
Name:BENNETT, NICOLE M (DC)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:M
Last Name:BENNETT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3725 BONITA BEACH RD STE 4
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-1400
Mailing Address - Country:US
Mailing Address - Phone:239-763-1288
Mailing Address - Fax:
Practice Address - Street 1:3725 BONITA BEACH RD STE 4
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-1400
Practice Address - Country:US
Practice Address - Phone:239-763-1288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8675111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381769501Medicaid
FL381769501Medicaid