Provider Demographics
NPI:1952481988
Name:BENNETT, ANDREA R (CRNA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:R
Last Name:BENNETT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 714960
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-4960
Mailing Address - Country:US
Mailing Address - Phone:205-322-1808
Mailing Address - Fax:205-322-1851
Practice Address - Street 1:1340 HAL GREER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3800
Practice Address - Country:US
Practice Address - Phone:205-322-1808
Practice Address - Fax:205-322-1851
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV43265367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00231145OtherPALMETTO GBA-RR MEDICARE
KY74443292Medicaid
WV0067966000Medicaid
OH0287041Medicaid
R89232Medicare UPIN
WV8215313Medicare ID - Type Unspecified