1083152367 NPI number — ANGELA BENNETT

Table of content: ANGELA BENNETT (NPI 1083152367)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083152367 NPI number — ANGELA BENNETT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNETT
Provider First Name:
ANGELA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083152367
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 OSBORNE RD NE
Provider Second Line Business Mailing Address:
SUITE 215
Provider Business Mailing Address City Name:
FRIDLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55432-2765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-236-2707
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 OSBORNE RD NE
Provider Second Line Business Practice Location Address:
SUITE 215
Provider Business Practice Location Address City Name:
FRIDLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55432-2765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-236-2707
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  1027 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1366440257 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1285887653 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1598191389 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1619938396 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396852091 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1942317888 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134225535 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com