Provider Demographics
NPI:1689709503
Name:BENNETT, SUSAN ELIZABETH
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ELIZABETH
Other - Last Name:ROGGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:901 W 112TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-5205
Mailing Address - Country:US
Mailing Address - Phone:816-942-5886
Mailing Address - Fax:
Practice Address - Street 1:2901 ROCKCREEK PKWY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64117-2536
Practice Address - Country:US
Practice Address - Phone:816-201-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS44573363LF0000X
MO112431363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOQ11144Medicare UPIN