Provider Demographics
NPI:1649204041
Name:BENNETT, KRISTINE M (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:M
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 PEACE HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-4851
Mailing Address - Country:US
Mailing Address - Phone:336-768-1280
Mailing Address - Fax:336-760-8443
Practice Address - Street 1:532 W PARK CIR
Practice Address - Street 2:
Practice Address - City:N WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3547
Practice Address - Country:US
Practice Address - Phone:336-667-6600
Practice Address - Fax:336-748-2666
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04920363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0451514334OtherBCBS PROVIDER ID#
IL85000828OtherLICENSE
IL0451514334OtherBCBS PROVIDER ID#
IL0727500001Medicare NSC
IL0727500001Medicare NSC
IL85000828OtherLICENSE