Provider Demographics
NPI:1356710693
Name:BENNETT, TAYLOR GRACE (CAA)
Entity type:Individual
Prefix:MRS
First Name:TAYLOR
Middle Name:GRACE
Last Name:BENNETT
Suffix:
Gender:
Credentials:CAA
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:GRACE
Other - Last Name:HENNESSY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAA
Mailing Address - Street 1:2995 DREW ST
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-315-7496
Mailing Address - Fax:
Practice Address - Street 1:300 PINELLAS ST
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3804
Practice Address - Country:US
Practice Address - Phone:813-870-4015
Practice Address - Fax:813-605-6269
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA297367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015710400Medicaid
FL015710400Medicaid