Provider Demographics
NPI:1619190212
Name:BENNETT, VIRGINIA H (CNS, APRN)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:H
Last Name:BENNETT
Suffix:
Gender:F
Credentials:CNS, APRN
Other - Prefix:
Other - First Name:GINNY
Other - Middle Name:
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CLINICAL NURSE SPECI
Mailing Address - Street 1:P.O BOX 1072
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06045
Mailing Address - Country:US
Mailing Address - Phone:860-647-1582
Mailing Address - Fax:860-647-1585
Practice Address - Street 1:223 EAST CENTER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040
Practice Address - Country:US
Practice Address - Phone:860-647-1582
Practice Address - Fax:860-647-1582
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00173363L00000X
CT0281025-01364SP0808X
CT001713364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
028102501OtherCLINICAL SPECIAL ADULT ME
CT4200284Medicaid
CT01713OtherAPRN
MB0326565OtherDEA
CT4200284Medicaid
028102501OtherCLINICAL SPECIAL ADULT ME