Provider Demographics
NPI:1497024541
Name:BENNETT, THERESA DELORES (FNP)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:DELORES
Last Name:BENNETT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:110 CENTRAL AVE
Mailing Address - Street 2:BOX 70
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827-1311
Mailing Address - Country:US
Mailing Address - Phone:607-687-5333
Mailing Address - Fax:607-687-4899
Practice Address - Street 1:110 CENTRAL AVE
Practice Address - Street 2:BOX 70
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827-1311
Practice Address - Country:US
Practice Address - Phone:607-687-5333
Practice Address - Fax:607-687-4899
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335938363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily