Provider Demographics
NPI:1992999270
Name:BENNETT, STEPHANIE R (PA-C)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:R
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:R
Other - Last Name:MELWANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 10744
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-8744
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:727-266-4943
Practice Address - Street 1:5999 DUNDEE RD
Practice Address - Street 2:SUITE 750
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-1107
Practice Address - Country:US
Practice Address - Phone:863-292-4077
Practice Address - Fax:863-292-4079
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105981363AM0700X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGA702ZMedicare PIN