Provider Demographics
NPI:1467891184
Name:WAUL-BENNETT, KANDICE KRISTEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KANDICE
Middle Name:KRISTEN
Last Name:WAUL-BENNETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5831 FORWARD AVE STE 1037
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15217-2301
Mailing Address - Country:US
Mailing Address - Phone:412-446-8058
Mailing Address - Fax:
Practice Address - Street 1:5831 FORWARD AVE STE 1037
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15217-2301
Practice Address - Country:US
Practice Address - Phone:412-446-8058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-15
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD459240207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103374197Medicaid