Provider Demographics
NPI:1760751358
Name:BENNETT, KERRY
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
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 1:8417 DRY CLIFF CIR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-7154
Mailing Address - Country:US
Mailing Address - Phone:818-917-5778
Mailing Address - Fax:
Practice Address - Street 1:8417 DRY CLIFF CIR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-7154
Practice Address - Country:US
Practice Address - Phone:818-917-5778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor