Healthcare Provider Details

I. General information

NPI: 1598219495
Provider Name (Legal Business Name): CARRIE E BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE E LOGAN CNP

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

547 E 11TH AVE
COLUMBUS OH
43211-2603
US

IV. Provider business mailing address

547 E 11TH AVE
COLUMBUS OH
43211-2603
US

V. Phone/Fax

Practice location:
  • Phone: 614-224-4506
  • Fax: 614-291-0118
Mailing address:
  • Phone: 614-224-4506
  • Fax: 614-291-0118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN414025
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.019788
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: