Provider Demographics
NPI:1326768300
Name:BENNETT, GARRETT LUKE
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:LUKE
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 1:5392 MORNING DR
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-1031
Mailing Address - Country:US
Mailing Address - Phone:610-755-8243
Mailing Address - Fax:
Practice Address - Street 1:799 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-1906
Practice Address - Country:US
Practice Address - Phone:419-756-5133
Practice Address - Fax:419-744-9707
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0020598367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty