Healthcare Provider Details

I. General information

NPI: 1306341458
Provider Name (Legal Business Name): ASHLEY BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 WILLIAMSON COUNTY PKWY
MARION IL
62959-5235
US

IV. Provider business mailing address

2914 N PARK AVE
HERRIN IL
62948-3522
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-3647
  • Fax: 618-959-9437
Mailing address:
  • Phone: 618-925-7790
  • Fax: 844-270-4161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.032324
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.445121
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: