Provider Demographics
NPI:1205669025
Name:BENNETT, ROBERT MAURICE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:MAURICE
Last Name:BENNETT
Suffix:
Gender:M
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 1:103 SAGAMORE DR S
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-2219
Mailing Address - Country:US
Mailing Address - Phone:803-456-0018
Mailing Address - Fax:
Practice Address - Street 1:3267 STATE ROUTE 11A
Practice Address - Street 2:
Practice Address - City:NEDROW
Practice Address - State:NY
Practice Address - Zip Code:13120-4507
Practice Address - Country:US
Practice Address - Phone:315-469-6449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY354332363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily