Provider Demographics
NPI:1750467452
Name:BENNETT, PAULA L (RNC)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:L
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 NORTHSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602
Mailing Address - Country:US
Mailing Address - Phone:229-241-2800
Mailing Address - Fax:229-241-0454
Practice Address - Street 1:220 NORTHSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:229-241-2800
Practice Address - Fax:229-241-0454
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR060585363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00530417BMedicaid
GA00530417BMedicaid
P32001Medicare UPIN