Ida Wallace Bennett Family Health Corporation

Primary specialty

Nurse PractitionerTaxonomy code 363L00000X

License

ARNP2155102 Issued in FL

Legal business name

IDA WALLACE BENNETT FAMILY HEALTH CORPORATION

Practice address

331 N Deerfield Ave
Deerfield Beach, FL 33441-2028

Phone

(561) 900-6737

Fax

(954) 422-1726

NPI assigned

Mar 1, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Pamela V Johnson, ARNP

Title

President

Phone

(561) 900-6737

Specialties & licenses 2

Addresses

Other identifiers 1

Other names 1

• Ida Wallace Bennett Family Corporation Former legal business name

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1172707200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1373932800000",
    "number": "1417085697",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "331 N DEERFIELD AVENUE",
            "city": "DEERFIELD BEACH",
            "state": "FL",
            "postal_code": "334412028",
            "telephone_number": "561-900-6737",
            "fax_number": "954-422-1726"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "331 N DEERFIELD AVE",
            "city": "DEERFIELD BEACH",
            "state": "FL",
            "postal_code": "334412028",
            "telephone_number": "561-900-6737",
            "fax_number": "954-422-1726"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IDA WALLACE BENNETT FAMILY HEALTH CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-01",
        "last_updated": "2013-07-16",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "PAMELA",
        "authorized_official_middle_name": "V",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "561-900-6737",
        "authorized_official_credential": "ARNP"
    },
    "taxonomies": [
        {
            "code": "261QH0100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Health Service",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner",
            "state": "FL",
            "license": "ARNP2155102",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PTAN AK407",
            "identifier": "BCBSFL",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ida Wallace Bennett Family Corporation",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 16, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.