Healthcare Provider Details

I. General information

NPI: 1265072714
Provider Name (Legal Business Name): COURTNEY ALLEEN BENNETT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2020
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 CHURCH ST NE
MARIETTA GA
30060-1101
US

IV. Provider business mailing address

55 WHITCHER ST NE STE 350
MARIETTA GA
30060-1129
US

V. Phone/Fax

Practice location:
  • Phone: 770-424-6893
  • Fax:
Mailing address:
  • Phone: 770-424-6893
  • Fax: 678-819-0357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN210038
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: