Provider Demographics
NPI:1356467989
Name:BENNETT, MARY JANE (NP-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 E CAMELBACK RD STE 700
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4245
Mailing Address - Country:US
Mailing Address - Phone:520-246-3971
Mailing Address - Fax:833-450-4452
Practice Address - Street 1:2415 E CAMELBACK RD STE 700
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4245
Practice Address - Country:US
Practice Address - Phone:520-246-3971
Practice Address - Fax:833-450-4452
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZA10235363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
009269OtherKAISER-COMMERCIAL NUMBER