Provider Demographics
NPI:1396463196
Name:BENNETT, CIERRA
Entity type:Individual
Prefix:
First Name:CIERRA
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 1:12401 S HIGHWAY 10
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:OK
Mailing Address - Zip Code:74370-2072
Mailing Address - Country:US
Mailing Address - Phone:417-270-6613
Mailing Address - Fax:
Practice Address - Street 1:12401 S HIGHWAY 10
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:OK
Practice Address - Zip Code:74370-2072
Practice Address - Country:US
Practice Address - Phone:417-270-6613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program