Provider Demographics
NPI:1104364173
Name:BENNETT, SARA RUTH (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:RUTH
Last Name:BENNETT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1975 HIGHWAY 54 W STE 255
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4794
Mailing Address - Country:US
Mailing Address - Phone:770-487-2218
Mailing Address - Fax:678-788-6909
Practice Address - Street 1:865 N HIGHLAND AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-4565
Practice Address - Country:US
Practice Address - Phone:404-733-6089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN165031363L00000X, 363LF0000X, 163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I503548Medicaid