Provider Demographics
NPI:1649204041
Name:BENNETT, KRISTINE M (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:M
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA-C
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 1845
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-1845
Mailing Address - Country:US
Mailing Address - Phone:704-873-4277
Mailing Address - Fax:
Practice Address - Street 1:152 SHERLOCK DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-1916
Practice Address - Country:US
Practice Address - Phone:704-838-8210
Practice Address - Fax:704-924-5359
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04920363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL85000828OtherLICENSE
IL0451514334OtherBCBS PROVIDER ID#
IL0451514334OtherBCBS PROVIDER ID#
IL0727500001Medicare NSC
IL0727500001Medicare NSC
IL85000828OtherLICENSE