Provider Demographics
NPI:1972120871
Name:BENNETT, CAROLYN ANNETTE (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:ANNETTE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 RIDGELAND FARMS RD W
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36105-6750
Mailing Address - Country:US
Mailing Address - Phone:912-321-8831
Mailing Address - Fax:
Practice Address - Street 1:RALPH H JOHNSON VA MEDICAL CENTER
Practice Address - Street 2:109 BEE STREET
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-5799
Practice Address - Country:US
Practice Address - Phone:912-408-2946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-168339163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse