Provider Demographics
NPI:1770551509
Name:BENNETT, CORTNEY BETH (PAC)
Entity type:Individual
Prefix:
First Name:CORTNEY
Middle Name:BETH
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1946 CHERRYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44312-3813
Mailing Address - Country:US
Mailing Address - Phone:330-620-5547
Mailing Address - Fax:
Practice Address - Street 1:3009 SMITH ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-3766
Practice Address - Country:US
Practice Address - Phone:330-836-8471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.001241RX363A00000X
OH50001241363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBEPA24691Medicare ID - Type Unspecified