Provider Demographics
NPI:1518743657
Name:BENNETT, KRISTIN MARIE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 RUTH LN
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-2629
Mailing Address - Country:US
Mailing Address - Phone:631-827-0967
Mailing Address - Fax:
Practice Address - Street 1:7 SEAFIELD LN
Practice Address - Street 2:
Practice Address - City:WESTHAMPTON BEACH
Practice Address - State:NY
Practice Address - Zip Code:11978-2719
Practice Address - Country:US
Practice Address - Phone:631-288-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY538604163W00000X
NYF352901-01363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered Nurse