Provider Demographics
NPI:1205421393
Name:BENNETT, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
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 474
Mailing Address - Street 2:
Mailing Address - City:ANSTED
Mailing Address - State:WV
Mailing Address - Zip Code:25812-0474
Mailing Address - Country:US
Mailing Address - Phone:304-640-8335
Mailing Address - Fax:
Practice Address - Street 1:90 TYREE STREET
Practice Address - Street 2:
Practice Address - City:ANSTED
Practice Address - State:WV
Practice Address - Zip Code:25812
Practice Address - Country:US
Practice Address - Phone:304-640-8335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty