Healthcare Provider Details

I. General information

NPI: 1588664742
Provider Name (Legal Business Name): JON DAVID BENNETT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 COUNTY RD
WINDSOR VT
05089-9000
US

IV. Provider business mailing address

36 BANK ST
NORTH BENNINGTON VT
05257-9101
US

V. Phone/Fax

Practice location:
  • Phone: 802-674-7036
  • Fax:
Mailing address:
  • Phone: 802-442-8315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number101-0012348
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: