Basic Information
| Provider Information | |||||||||
| NPI: | 1902346141 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | KINNEATHEA | ||||||||
| MiddleName: | DENISHA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 KIRTS BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480844135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488246623 | ||||||||
| FaxNumber: | 8666186655 | ||||||||
| Practice Location | |||||||||
| Address1: | 5414 FREDERICKSBURG RD STE 100A | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104680800 | ||||||||
| FaxNumber: | 2107338649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2017 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | AP133353 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 370823204 | 05 | TX | MEDICAID | AG0117008 | 01 | TX | AMERICAN ACADEMY OF NURSE PRACTITIONERS | OTHER |