Provider Demographics
NPI:1154588119
Name:BENNETT, CLARK ALLAN (RN)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:ALLAN
Last Name:BENNETT
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 STATE ROAD 23
Mailing Address - Street 2:
Mailing Address - City:MINERAL POINT
Mailing Address - State:WI
Mailing Address - Zip Code:53565-8911
Mailing Address - Country:US
Mailing Address - Phone:608-987-3094
Mailing Address - Fax:608-987-3904
Practice Address - Street 1:720 WOOD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4413
Practice Address - Country:US
Practice Address - Phone:707-268-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI130599-30163W00000X
CA4720618163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse