Provider Demographics
NPI:1942658422
Name:BENNETT, LATYEASARAL MONQUELLA (NP)
Entity Type:Individual
Prefix:
First Name:LATYEASARAL
Middle Name:MONQUELLA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 S GENERALS BLVD
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28092-3658
Mailing Address - Country:US
Mailing Address - Phone:704-736-9188
Mailing Address - Fax:
Practice Address - Street 1:7845 LITTLE AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-8198
Practice Address - Country:US
Practice Address - Phone:704-375-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5008577363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily