Healthcare Provider Details

I. General information

NPI: 1902122591
Provider Name (Legal Business Name): AUDREY PHILLIPS BENNETT CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10175 LITTLE PATUXENT PKWY
COLUMBIA MD
21044-2655
US

IV. Provider business mailing address

224 LIGHTHOUSE DR
DOTHAN AL
36305-7302
US

V. Phone/Fax

Practice location:
  • Phone: 251-604-4785
  • Fax:
Mailing address:
  • Phone: 334-798-1555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberA0310068
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: