Healthcare Provider Details

I. General information

NPI: 1285583880
Provider Name (Legal Business Name): KEIRSTIN BENNETT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2026
Last Update Date: 01/26/2026
Certification Date: 01/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 TOLEDO AVE
MORIARTY NM
87035-5520
US

IV. Provider business mailing address

5 TOLEDO AVE
MORIARTY NM
87035-5520
US

V. Phone/Fax

Practice location:
  • Phone: 505-542-9795
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number72715
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: