Healthcare Provider Details

I. General information

NPI: 1881836203
Provider Name (Legal Business Name): SHANNON M. BENNETT D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2009
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

IV. Provider business mailing address

39 HOLMES RD
SACO ME
04072-9364
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-2541
  • Fax:
Mailing address:
  • Phone: 207-604-0391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDO2387
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberDO2387
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: