Provider Demographics
NPI:1700248713
Name:BENNETT, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
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 1:113 W CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:PA
Mailing Address - Zip Code:17078-2303
Mailing Address - Country:US
Mailing Address - Phone:303-870-1954
Mailing Address - Fax:
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-558-4831
Practice Address - Fax:513-558-4858
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.145966207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program