Provider Demographics
NPI:1417398124
Name:BENNETT, MARY KEELY COSTELLO (AGACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KEELY COSTELLO
Last Name:BENNETT
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Gender:F
Credentials:AGACNP-BC
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Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:EMERGENCY MEDICINE
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5051
Practice Address - Country:US
Practice Address - Phone:804-828-5650
Practice Address - Fax:804-828-4686
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2019-02-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0024170989363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care