Provider Demographics
NPI:1336678044
Name:BENNETT, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
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 1:407 FAIRFAX DR APT 32
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35064-1063
Mailing Address - Country:US
Mailing Address - Phone:205-370-0686
Mailing Address - Fax:
Practice Address - Street 1:407 FAIRFAX DR APT 32
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:AL
Practice Address - Zip Code:35064-1063
Practice Address - Country:US
Practice Address - Phone:205-370-0686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1320341744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management