Provider Demographics
NPI:1417432089
Name:BENNETT, PEYTON
Entity Type:Individual
Prefix:
First Name:PEYTON
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 1:8787 NW COUNTY ROAD 2109
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-8528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8787 NW COUNTY ROAD 2109
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-8528
Practice Address - Country:US
Practice Address - Phone:430-236-9172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-30
Last Update Date:2018-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX339581164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse