Provider Demographics
NPI:1962129361
Name:BENNETT, MARY AGNES (FNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:AGNES
Last Name:BENNETT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MAGNOLIA CROSSING RD
Mailing Address - Street 2:
Mailing Address - City:SUMRALL
Mailing Address - State:MS
Mailing Address - Zip Code:39482-7003
Mailing Address - Country:US
Mailing Address - Phone:601-516-0260
Mailing Address - Fax:
Practice Address - Street 1:35 MAGNOLIA CROSSING RD
Practice Address - Street 2:
Practice Address - City:SUMRALL
Practice Address - State:MS
Practice Address - Zip Code:39482-7003
Practice Address - Country:US
Practice Address - Phone:160-151-6026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN32850363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily