Basic Information
| Provider Information | |||||||||
| NPI: | 1538356837 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | HEATHER | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2476 CANTON RD | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300665377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709511565 | ||||||||
| FaxNumber: | 7705739513 | ||||||||
| Practice Location | |||||||||
| Address1: | 2476 CANTON RD | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300665377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709511565 | ||||||||
| FaxNumber: | 7705739513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 03/11/2019 | ||||||||
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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 | 163W00000X | 1-073471 | AL | N | Nursing Service Providers | Registered Nurse | 363L00000X | RN237110 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 28240019A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.