Provider Demographics
NPI:1861427205
Name:BENNETT, LAINE (FNP)
Entity type:Individual
Prefix:
First Name:LAINE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ARBORLAND WAY
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-2201
Mailing Address - Country:US
Mailing Address - Phone:864-297-6010
Mailing Address - Fax:864-458-7673
Practice Address - Street 1:12 ARBORLAND WAY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-2201
Practice Address - Country:US
Practice Address - Phone:864-297-6010
Practice Address - Fax:864-458-7673
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN2270363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPO753Medicaid
SCAA87265193OtherMEDICARE PIN
SCS775398157Medicare PIN