Provider Demographics
NPI:1174293138
Name:BENNETT, JUSTIN BAINES
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:BAINES
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4314 WILLIAMSTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26187-8083
Mailing Address - Country:US
Mailing Address - Phone:304-482-6029
Mailing Address - Fax:
Practice Address - Street 1:4314 WILLIAMSTOWN PIKE
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:WV
Practice Address - Zip Code:26187-8083
Practice Address - Country:US
Practice Address - Phone:304-482-6029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.385551163WH0200X
OHLE-00038485207Q00000X
WV110892363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine