Provider Demographics
NPI:1780145714
Name:BENNETT, KATETIA H
Entity type:Individual
Prefix:PROF
First Name:KATETIA
Middle Name:H
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 1:3837 CRUSADE DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2252
Mailing Address - Country:US
Mailing Address - Phone:336-983-3046
Mailing Address - Fax:877-445-5698
Practice Address - Street 1:3500 VEST MILL RD STE 33
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2978
Practice Address - Country:US
Practice Address - Phone:336-934-5354
Practice Address - Fax:877-445-5698
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-31
Last Update Date:2019-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC202876163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health