Provider Demographics
NPI:1508330184
Name:BENNETT, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
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 1:106 E GAMBIER ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-3510
Mailing Address - Country:US
Mailing Address - Phone:740-397-2660
Mailing Address - Fax:740-392-3613
Practice Address - Street 1:106 E GAMBIER ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-3510
Practice Address - Country:US
Practice Address - Phone:740-397-2660
Practice Address - Fax:740-392-3613
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty