Basic Information
| Provider Information | |||||||||
| NPI: | 1821440694 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAGER-BENNETT | ||||||||
| FirstName: | JUSTINE | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2555 S ATLANTIC AVE APT 1604 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH SHORES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321185537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3865667431 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 MEMORIAL MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321175167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862316000 | ||||||||
| FaxNumber: | 3177055047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2016 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | APRN3198542 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.