Provider Demographics
NPI:1043086879
Name:BENNETT, STEPHANIE FAYE
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:FAYE
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 1:5661 OCMULGEE EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-5797
Mailing Address - Country:US
Mailing Address - Phone:478-960-9592
Mailing Address - Fax:
Practice Address - Street 1:101 GATEWAY DRIVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210
Practice Address - Country:US
Practice Address - Phone:478-210-1670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN251069207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine