Provider Demographics
NPI:1942176748
Name:BENNETT, SHERTIAL RENEE
Entity type:Individual
Prefix:
First Name:SHERTIAL
Middle Name:RENEE
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:PO BOX 301
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:TX
Mailing Address - Zip Code:75409-0301
Mailing Address - Country:US
Mailing Address - Phone:972-850-6224
Mailing Address - Fax:
Practice Address - Street 1:7777 WARREN PKWY
Practice Address - Street 2:MATTISON AVENUE SALON SUITES AND SPA SUITE 105
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-6549
Practice Address - Country:US
Practice Address - Phone:972-850-6224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-17
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1204023335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier