Provider Demographics
NPI:1851608905
Name:BENNETT, CHALONNIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:CHALONNIE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 NEAL ST
Mailing Address - Street 2:
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-8035
Mailing Address - Country:US
Mailing Address - Phone:912-271-1387
Mailing Address - Fax:
Practice Address - Street 1:126 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-8952
Practice Address - Country:US
Practice Address - Phone:912-271-1387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2021-06-16
Deactivation Date:2017-02-15
Deactivation Code:
Reactivation Date:2021-06-16
Provider Licenses
StateLicense IDTaxonomies
GARN170946163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse