Provider Demographics
NPI:1174798011
Name:BENNETT, MARY T (MSN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:T
Other - Last Name:BOSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN
Mailing Address - Street 1:9040 A REID ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-968-3162
Mailing Address - Fax:253-968-3278
Practice Address - Street 1:9040 A REID ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-3162
Practice Address - Fax:253-968-3278
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004436363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA331-8907Medicaid
WAVAD000Medicare UPIN