Provider Demographics
NPI:1912995010
Name:BENNETT, REGINA M (NP)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:M
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:PO BOX 860
Mailing Address - Street 2:
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941-0860
Mailing Address - Country:US
Mailing Address - Phone:928-338-4911
Mailing Address - Fax:928-338-5508
Practice Address - Street 1:200 W. HOSPITAL DR.
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941-0860
Practice Address - Country:US
Practice Address - Phone:928-338-4911
Practice Address - Fax:928-338-5508
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332949363LF0000X
FLARNP1220062363LF0000X
GA227601363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308463900Medicaid
FL308463900Medicaid
FL308463900Medicaid