Basic Information
| Provider Information | |||||||||
| NPI: | 1447261771 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETHUM | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 MARYLAND RD | ||||||||
| Address2: | SUITE 20 | ||||||||
| City: | WILLOW GROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190901700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158308700 | ||||||||
| FaxNumber: | 2158308715 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 MARYLAND RD | ||||||||
| Address2: | SUITE 20 | ||||||||
| City: | WILLOW GROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190901700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158308700 | ||||||||
| FaxNumber: | 2158308715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 01/12/2016 | ||||||||
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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 | 363AM0700X | MA-051528 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.