Provider Demographics
NPI:1588042105
Name:BENNETT, GINA
Entity Type:Individual
Prefix:
First Name:GINA
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 1:100 E. LANCASTER AVE
Mailing Address - Street 2:ST 130
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 E. LANCASTER AVE
Practice Address - Street 2:ST 130
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096
Practice Address - Country:US
Practice Address - Phone:610-649-1175
Practice Address - Fax:610-896-8753
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN530235L363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner