Provider Demographics
NPI:1821832817
Name:BENNETT, EMILY GRACE (PA-C)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:GRACE
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 1:800 WESTERLY DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-9578
Mailing Address - Country:US
Mailing Address - Phone:601-941-3545
Mailing Address - Fax:
Practice Address - Street 1:971 LAKELAND DR STE 250
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4620
Practice Address - Country:US
Practice Address - Phone:662-803-5763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA-00809207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine