Provider Demographics
NPI:1073260584
Name:BENNETT, CLAIRE ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:CLAIRE
Middle Name:ELIZABETH
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 W AUGUSTA BLVD APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-8661
Mailing Address - Country:US
Mailing Address - Phone:856-449-1384
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 425
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3893
Practice Address - Country:US
Practice Address - Phone:312-563-2578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008826363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant