Provider Demographics
NPI:1336181536
Name:BENNETT, SALLY D (APRN BC FNP)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:D
Last Name:BENNETT
Suffix:
Gender:F
Credentials:APRN BC FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 N GROSS RD STE 201
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-6277
Mailing Address - Country:US
Mailing Address - Phone:912-729-2795
Mailing Address - Fax:912-729-4117
Practice Address - Street 1:130 N GROSS RD
Practice Address - Street 2:STE 201
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548
Practice Address - Country:US
Practice Address - Phone:912-729-2795
Practice Address - Fax:912-729-4117
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN094886363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5000021728OtherRR MC
GA00830244CMedicaid
GA00830244DMedicaid
S84551Medicare UPIN
GA00830244CMedicaid