Healthcare Provider Details

I. General information

NPI: 1043086879
Provider Name (Legal Business Name): MRS. STEPHANIE FAYE BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 FORSYTH ST
MACON GA
31201-2051
US

IV. Provider business mailing address

5661 OCMULGEE EAST BLVD
MACON GA
31217-5797
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-8100
  • Fax:
Mailing address:
  • Phone: 478-960-9592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRN251069
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberRN251069
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: