Provider Demographics
NPI:1245969062
Name:BENNETT, AMY KRISTINA (RN, NP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:KRISTINA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6306 SEAMAN ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-2626
Mailing Address - Country:US
Mailing Address - Phone:858-205-3306
Mailing Address - Fax:
Practice Address - Street 1:6306 SEAMAN ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-2626
Practice Address - Country:US
Practice Address - Phone:858-205-3306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA495091163W00000X
CA11019363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse