Provider Demographics
NPI:1215177464
Name:BENNETT, KATIE RAE (NP-C)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:RAE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 WYMAN PARK DR
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2803
Mailing Address - Country:US
Mailing Address - Phone:410-338-3500
Mailing Address - Fax:
Practice Address - Street 1:1000 E EAGER ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-5533
Practice Address - Country:US
Practice Address - Phone:410-522-9800
Practice Address - Fax:410-522-5136
Is Sole Proprietor?:No
Enumeration Date:2009-03-01
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR158893363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily