Healthcare Provider Details

I. General information

NPI: 1356252803
Provider Name (Legal Business Name): KIMBERLY ELLEN BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

7472 GARETT PARK DR
WHITSETT NC
27377-9606
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-2011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number160176
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: