Basic Information
| Provider Information | |||||||||
| NPI: | 1023321882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT WILKE | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2406 E PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323085301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504314556 | ||||||||
| FaxNumber: | 8504316315 | ||||||||
| Practice Location | |||||||||
| Address1: | 2406 E PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323085301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504314556 | ||||||||
| FaxNumber: | 8504316315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2010 | ||||||||
| LastUpdateDate: | 11/20/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9105489 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.