Provider Demographics
NPI:1548748700
Name:BENNER, CAROL ANN (RN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:BENNER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 PARKER HILL AVE
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02120-3331
Mailing Address - Country:US
Mailing Address - Phone:267-421-1178
Mailing Address - Fax:
Practice Address - Street 1:780 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2755
Practice Address - Country:US
Practice Address - Phone:857-654-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2326279163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse