Healthcare Provider Details

I. General information

NPI: 1235834649
Provider Name (Legal Business Name): SHENIEKA KASHEKA BENNETT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 S MARTIN LUTHER KING BLVD U.S. 280
AMERICUS GA
31719
US

IV. Provider business mailing address

765 RIVER GARDENS DR
ATLANTA GA
30354-4402
US

V. Phone/Fax

Practice location:
  • Phone: 229-924-6011
  • Fax:
Mailing address:
  • Phone: 786-520-9799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number111579
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: