Provider Demographics
NPI:1669646048
Name:BENNERMAN, MARY P (RD, LDN, CDE)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:P
Last Name:BENNERMAN
Suffix:
Gender:F
Credentials:RD, LDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 RAEFORD RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-0807
Mailing Address - Country:US
Mailing Address - Phone:910-488-2120
Mailing Address - Fax:
Practice Address - Street 1:7300 S RAEFORD RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-6162
Practice Address - Country:US
Practice Address - Phone:910-475-6296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL000337133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist