Provider Demographics
NPI:1588603641
Name:BENNETT, STEPHANIE B (DO)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:B
Last Name:BENNETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 LINE RD
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-3320
Mailing Address - Country:US
Mailing Address - Phone:610-644-5993
Mailing Address - Fax:610-407-9045
Practice Address - Street 1:229 LINE RD
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-3320
Practice Address - Country:US
Practice Address - Phone:610-644-5993
Practice Address - Fax:610-407-9045
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009106L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017367030003Medicaid
PA0017367030003Medicaid
PA012240Medicare ID - Type Unspecified