Provider Demographics
NPI:1902122591
Name:BENNETT, AUDREY PHILLIPS (CRNP)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:PHILLIPS
Last Name:BENNETT
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 LIGHTHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-7302
Mailing Address - Country:US
Mailing Address - Phone:334-798-1555
Mailing Address - Fax:
Practice Address - Street 1:10175 LITTLE PATUXENT PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2655
Practice Address - Country:US
Practice Address - Phone:251-604-4785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALA0310068363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALA0310068OtherCERTIFIED NURSE PRACTITIONER NUMBER