Healthcare Provider Details

I. General information

NPI: 1710701446
Provider Name (Legal Business Name): STEPHANIE AMBER BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 11/11/2024
Certification Date: 11/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK ST
NEW HAVEN CT
06510-3202
US

IV. Provider business mailing address

95 HOWLANDS LN
KINGSTON MA
02364-1640
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-4242
  • Fax:
Mailing address:
  • Phone: 774-204-4886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number208836
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: