Provider Demographics
NPI:1588664742
Name:BENNETT, JON DAVID (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:DAVID
Last Name:BENNETT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 BANK ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05257-9101
Mailing Address - Country:US
Mailing Address - Phone:802-442-8315
Mailing Address - Fax:
Practice Address - Street 1:289 COUNTY RD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:VT
Practice Address - Zip Code:05089-9000
Practice Address - Country:US
Practice Address - Phone:802-674-7036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0012348367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0009341Medicaid
VTVT9341Medicare ID - Type Unspecified