Provider Demographics
NPI:1013090786
Name:BENNETT, TAMMY (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1757 WOODRUFF RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-6943
Mailing Address - Country:US
Mailing Address - Phone:864-458-9288
Mailing Address - Fax:864-458-9289
Practice Address - Street 1:1757 WOODRUFF RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-6943
Practice Address - Country:US
Practice Address - Phone:864-458-9288
Practice Address - Fax:864-458-9289
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3073363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1077Medicaid
SCNP1077Medicaid
SCAA1684Medicare PIN