Provider Demographics
NPI:1033444088
Name:BENNIE, BRIA LEIGH (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIA
Middle Name:LEIGH
Last Name:BENNIE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 PARK PLACE BLVD. BLDG. D
Mailing Address - Street 2:SUITE 3
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-2358
Mailing Address - Country:US
Mailing Address - Phone:407-944-4900
Mailing Address - Fax:407-483-0688
Practice Address - Street 1:102 PARK PLACE BLVD STE 3
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2358
Practice Address - Country:US
Practice Address - Phone:407-944-4900
Practice Address - Fax:407-483-0688
Is Sole Proprietor?:No
Enumeration Date:2009-10-08
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9105229363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45-5436649Medicaid