Provider Demographics
NPI:1215376405
Name:BENNETT, MARIE G (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:G
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 1:819 WORCESTER ST
Mailing Address - Street 2:STE 3
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01151-1045
Mailing Address - Country:US
Mailing Address - Phone:413-543-6820
Mailing Address - Fax:413-543-7962
Practice Address - Street 1:200 GROTON RD
Practice Address - Street 2:
Practice Address - City:AYER
Practice Address - State:MA
Practice Address - Zip Code:01432-1168
Practice Address - Country:US
Practice Address - Phone:978-784-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2265713363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110099188AMedicaid
MA110099188AMedicaid
MAS400143149Medicare PIN