Provider Demographics
NPI:1699129726
Name:BENNETT, ANGELA (PTA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14809 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66215-5220
Mailing Address - Country:US
Mailing Address - Phone:913-894-6664
Mailing Address - Fax:
Practice Address - Street 1:14809 W 95TH ST
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215-5220
Practice Address - Country:US
Practice Address - Phone:913-894-6664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02986225200000X
MO2016008266225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant