Provider Demographics
NPI:1093813370
Name:BENNETT, CAROL A (ARNP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-5042
Mailing Address - Country:US
Mailing Address - Phone:386-328-8371
Mailing Address - Fax:386-328-1519
Practice Address - Street 1:1302 RIVER ST
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-5042
Practice Address - Country:US
Practice Address - Phone:386-328-8371
Practice Address - Fax:386-328-1519
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1550822363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308868500Medicaid
FLY0568OtherBCBS PROVIDER #
FLY0568OtherBCBS PROVIDER #
FLP42110Medicare UPIN