Healthcare Provider Details

I. General information

NPI: 1356073340
Provider Name (Legal Business Name): ALEXIS BAYLEE BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 MERCER UNIVERSITY DR
MACON GA
31207-1515
US

IV. Provider business mailing address

238 WHITE OAKS CIR
BLUFFTON SC
29910-5704
US

V. Phone/Fax

Practice location:
  • Phone: 800-637-2378
  • Fax:
Mailing address:
  • Phone: 843-540-2853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: