Healthcare Provider Details

I. General information

NPI: 1013979079
Provider Name (Legal Business Name): SHANON DIONE BENNETT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANON DIONE ROELFS PA-C

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1731 W RIDGEWAY AVE STE 100
WATERLOO IA
50701-4591
US

IV. Provider business mailing address

1731 W RIDGEWAY AVE STE 100
WATERLOO IA
50701-4591
US

V. Phone/Fax

Practice location:
  • Phone: 319-833-5888
  • Fax: 319-833-5891
Mailing address:
  • Phone: 319-833-5888
  • Fax: 319-833-5891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001016
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001000136
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: