Provider Demographics
NPI:1417738956
Name:BENNETTO, KELLY ANN (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:BENNETTO
Suffix:
Gender:F
Credentials:FNP
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 101
Mailing Address - Street 2:
Mailing Address - City:SHEPHERD
Mailing Address - State:MT
Mailing Address - Zip Code:59079-0101
Mailing Address - Country:US
Mailing Address - Phone:406-500-1858
Mailing Address - Fax:
Practice Address - Street 1:7814 BUCKSKIN DR
Practice Address - Street 2:
Practice Address - City:SHEPHERD
Practice Address - State:MT
Practice Address - Zip Code:59079-4521
Practice Address - Country:US
Practice Address - Phone:406-500-1858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-219555363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily