Provider Demographics
NPI:1336476282
Name:BENNETT, STEPHENIE (PA)
Entity Type:Individual
Prefix:
First Name:STEPHENIE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-0146
Mailing Address - Country:US
Mailing Address - Phone:360-565-0999
Mailing Address - Fax:360-565-7610
Practice Address - Street 1:433 E 8TH ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6219
Practice Address - Country:US
Practice Address - Phone:360-565-0999
Practice Address - Fax:360-565-7610
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60115661363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant