1972120871 NPI number — MRS. CAROLYN ANNETTE BENNETT REGISTERED NURSE

Table of content: MRS. CAROLYN ANNETTE BENNETT REGISTERED NURSE (NPI 1972120871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972120871 NPI number — MRS. CAROLYN ANNETTE BENNETT REGISTERED NURSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNETT
Provider First Name:
CAROLYN
Provider Middle Name:
ANNETTE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
REGISTERED NURSE
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:
1972120871
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 RIDGELAND FARMS RD W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36105-6750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-321-8831
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
RALPH H JOHNSON VA MEDICAL CENTER
Provider Second Line Business Practice Location Address:
109 BEE STREET
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29401-5799
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-408-2946
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2020

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: 163W00000X , with the licence number:  1-168339 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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