Provider Demographics
NPI:1902346141
Name:BENNETT, KINNEATHEA DENISHA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:KINNEATHEA
Middle Name:DENISHA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
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Mailing Address - Street 1:500 KIRTS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4135
Mailing Address - Country:US
Mailing Address - Phone:248-824-6623
Mailing Address - Fax:866-618-6655
Practice Address - Street 1:5414 FREDERICKSBURG RD STE 100A
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3641
Practice Address - Country:US
Practice Address - Phone:210-468-0800
Practice Address - Fax:210-733-8649
Is Sole Proprietor?:No
Enumeration Date:2017-03-07
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXAP133353363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX370823204Medicaid
TXAG0117008OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS