# IDA WALLACE BENNETT FAMILY HEALTH CORPORATION

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Ida Wallace Bennett Family Corporation
- **Organization subpart:** No

## Provider details

- **NPI number:** 1417085697
- **Authorized official:** PAMELA V JOHNSON ARNP (PRESIDENT)
- **Authorized official phone:** (561) 900-6737

## Contact information

- **Practice address:** 331 N DEERFIELD AVE, DEERFIELD BEACH, FL 33441-2028
- **Practice address phone:** (561) 900-6737
- **Practice address fax:** (954) 422-1726
- **Mailing address:** 331 N DEERFIELD AVENUE, DEERFIELD BEACH, FL 33441-2028
- **Mailing address phone:** (561) 900-6737
- **Mailing address fax:** (954) 422-1726

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QH0100X | Health Service Clinic/Center | — | — | — |
| 363L00000X | Nurse Practitioner | ARNP2155102 | FL | Yes |

## Other

- **Enumeration date:** 03/01/2007
- **Last updated:** 07/16/2013

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | BCBSFL | PTAN AK407 | FL |