Provider Demographics
NPI:1548850134
Name:BENTZ, MARIE ELIANTHE (FNP)
Entity type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:ELIANTHE
Last Name:BENTZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5722 E STILLWATER AVE UNIT 8
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-3187
Mailing Address - Country:US
Mailing Address - Phone:714-465-0875
Mailing Address - Fax:
Practice Address - Street 1:5722 E STILLWATER AVE UNIT 8
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-3187
Practice Address - Country:US
Practice Address - Phone:714-465-0875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013446207Q00000X
AZ261026363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty