Provider Demographics
NPI:1851084859
Name:BENNETT, ELISABETH ANN
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:ANN
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 1:38 21ST ST
Mailing Address - Street 2:
Mailing Address - City:MCMECHEN
Mailing Address - State:WV
Mailing Address - Zip Code:26040-1109
Mailing Address - Country:US
Mailing Address - Phone:304-905-0873
Mailing Address - Fax:
Practice Address - Street 1:38 21ST ST
Practice Address - Street 2:
Practice Address - City:MCMECHEN
Practice Address - State:WV
Practice Address - Zip Code:26040-1109
Practice Address - Country:US
Practice Address - Phone:304-905-0873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV125553494Medicaid
WV1356607394Medicaid
WV1821206228Medicaid