Provider Demographics
NPI:1265875819
Name:BENNETT, DEBRA EILEEN (NP)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:EILEEN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3554 BACONTREE PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-4728
Mailing Address - Country:US
Mailing Address - Phone:619-540-0283
Mailing Address - Fax:
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:SUITE 570
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1224
Practice Address - Country:US
Practice Address - Phone:858-200-3007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-14
Last Update Date:2013-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22962363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner