1063489086 NPI number — PROF. MARY P BENNETT PHD, ARNP

Table of content: PROF. MARY P BENNETT PHD, ARNP (NPI 1063489086)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063489086 NPI number — PROF. MARY P BENNETT PHD, ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNETT
Provider First Name:
MARY
Provider Middle Name:
P
Provider Name Prefix Text:
PROF.
Provider Name Suffix Text:
Provider Credential Text:
PHD, ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063489086
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1906 COLLEGE HEIGHTS BOLV #11036
Provider Second Line Business Mailing Address:
WKU SCHOOL OF NURSING ACADEMIC COMPLEX ROOM 113 D
Provider Business Mailing Address City Name:
BOWLING GREEN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42101-1036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-745-3590
Provider Business Mailing Address Fax Number:
270-745-3392

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1906 COLLEGE HEIGHTS BOLV #11036
Provider Second Line Business Practice Location Address:
WKU SCHOOL OF NURSING ACADEMIC COMPLEX ROOM 113 D
Provider Business Practice Location Address City Name:
BOWLING GREEN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42101-1036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-745-3590
Provider Business Practice Location Address Fax Number:
270-745-3392
Provider Enumeration Date:
03/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  71001945A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 5351P , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)