Provider Demographics
NPI:1992137368
Name:BENNETT, TARA ALEA (FNP)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:ALEA
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 1:500 LAKESHORE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-4273
Mailing Address - Country:US
Mailing Address - Phone:803-818-6955
Mailing Address - Fax:803-818-6993
Practice Address - Street 1:500 LAKESHORE PKWY
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-4273
Practice Address - Country:US
Practice Address - Phone:803-818-6955
Practice Address - Fax:803-818-6993
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2628Medicaid