Provider Demographics
NPI:1356967962
Name:BENNETT, STACEY (DPH)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7760 TRINITY RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-2739
Mailing Address - Country:US
Mailing Address - Phone:901-737-9720
Mailing Address - Fax:
Practice Address - Street 1:7760 TRINITY RD STE 101
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-2739
Practice Address - Country:US
Practice Address - Phone:901-737-9720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN89091835N0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835N0905XPharmacy Service ProvidersPharmacistNuclear