Provider Demographics
NPI:1144680034
Name:BENNETT, CASEY JO
Entity type:Individual
Prefix:
First Name:CASEY JO
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1948 OLD OCILLA RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794
Mailing Address - Country:US
Mailing Address - Phone:229-391-3500
Mailing Address - Fax:
Practice Address - Street 1:115 31ST AVE SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6771
Practice Address - Country:US
Practice Address - Phone:229-502-9788
Practice Address - Fax:229-890-2166
Is Sole Proprietor?:No
Enumeration Date:2016-03-04
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN188746363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology