Healthcare Provider Details

I. General information

NPI: 1558580860
Provider Name (Legal Business Name): RUSSELL BENNETT BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 KESSEL CT STE 105
MADISON WI
53711-6227
US

IV. Provider business mailing address

25 KESSEL CT
MADISON WI
53711-6227
US

V. Phone/Fax

Practice location:
  • Phone: 608-280-2700
  • Fax:
Mailing address:
  • Phone: 608-280-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number90892
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: