Provider Demographics
NPI:1750836169
Name:BENNETT, KERI LYN
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:LYN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3402 FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-6932
Mailing Address - Country:US
Mailing Address - Phone:208-642-6416
Mailing Address - Fax:
Practice Address - Street 1:515 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-2774
Practice Address - Country:US
Practice Address - Phone:208-642-6416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID46146163W00000X
OR201392585RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse