Healthcare Provider Details

I. General information

NPI: 1952746067
Provider Name (Legal Business Name): MICHAEL SCOTT BENNETT M.S.N., R.N., C.N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3605 WARRENSVILLE CENTER RD 2362-H
SHAKER HEIGHTS OH
44122-5203
US

IV. Provider business mailing address

13085 GAR HWY
CHARDON OH
44024-9206
US

V. Phone/Fax

Practice location:
  • Phone: 216-952-0955
  • Fax:
Mailing address:
  • Phone: 773-307-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCOA.14306-NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberCOA.14306-NP
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.388869-COA1
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: