Provider Demographics
NPI:1225685548
Name:BENNETT, CAROLYN BONITA
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:BONITA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-9348
Mailing Address - Country:US
Mailing Address - Phone:772-216-2815
Mailing Address - Fax:
Practice Address - Street 1:808 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-9348
Practice Address - Country:US
Practice Address - Phone:772-216-2815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9999999999Medicaid