Provider Demographics
NPI:1801153358
Name:BENNETT, ERIN
Entity type:Individual
Prefix:
First Name:ERIN
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 1:1563 ALVAMAR CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-1713
Mailing Address - Country:US
Mailing Address - Phone:785-865-9980
Mailing Address - Fax:
Practice Address - Street 1:100 MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113
Practice Address - Country:US
Practice Address - Phone:801-662-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT8771414-12052080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program