Provider Demographics
NPI:1033777644
Name:BENNETT, MADISON TAYLOR
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:TAYLOR
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 LONE STAR RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38464-7196
Mailing Address - Country:US
Mailing Address - Phone:931-242-5610
Mailing Address - Fax:
Practice Address - Street 1:409 LONE STAR RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-7196
Practice Address - Country:US
Practice Address - Phone:931-242-5610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty