Provider Demographics
NPI:1568290492
Name:BENNETT, CORY JOHN
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:JOHN
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8621 BUCKLEBURY DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-1429
Mailing Address - Country:US
Mailing Address - Phone:732-421-7656
Mailing Address - Fax:
Practice Address - Street 1:8621 BUCKLEBURY DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-1429
Practice Address - Country:US
Practice Address - Phone:732-421-7656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program