Healthcare Provider Details

I. General information

NPI: 1538596945
Provider Name (Legal Business Name): TRISHA C BENNETT RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2013
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2064 PRAIRIE MEADOW DR
KRONENWETTER WI
54455-8193
US

IV. Provider business mailing address

2064 PRAIRIE MEADOW DR
KRONENWETTER WI
54455-8193
US

V. Phone/Fax

Practice location:
  • Phone: 715-676-0300
  • Fax:
Mailing address:
  • Phone: 715-676-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number154549-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: