Provider Demographics
NPI:1063082154
Name:BENNETT, ALICIA MARIE (RN)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3533 NW 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33309-5330
Mailing Address - Country:US
Mailing Address - Phone:954-842-9778
Mailing Address - Fax:
Practice Address - Street 1:3533 NW 37TH AVE
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33309-5330
Practice Address - Country:US
Practice Address - Phone:954-842-9778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11031454367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered