Provider Demographics
NPI:1568240307
Name:BENNETT, REGGIE (CAA)
Entity Type:Individual
Prefix:
First Name:REGGIE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4616 TUTEN DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:GA
Mailing Address - Zip Code:31518-3206
Mailing Address - Country:US
Mailing Address - Phone:912-424-0538
Mailing Address - Fax:
Practice Address - Street 1:800 PRUDENTIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8202
Practice Address - Country:US
Practice Address - Phone:904-202-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA789789989367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant