Provider Demographics
NPI:1235634643
Name:BENNETT, SHANICE JANAE
Entity Type:Individual
Prefix:
First Name:SHANICE
Middle Name:JANAE
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 1:104 MEMPHIS CT
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-6286
Mailing Address - Country:US
Mailing Address - Phone:843-810-3778
Mailing Address - Fax:
Practice Address - Street 1:9200 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9121
Practice Address - Country:US
Practice Address - Phone:843-863-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program