Provider Demographics
NPI:1558132647
Name:BENNETT, HEIDI ROSE (MS)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:ROSE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6768 APRICOT RD
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-5117
Mailing Address - Country:US
Mailing Address - Phone:912-670-5241
Mailing Address - Fax:
Practice Address - Street 1:6768 APRICOT RD
Practice Address - Street 2:
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516-5117
Practice Address - Country:US
Practice Address - Phone:912-670-5241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education