Healthcare Provider Details

I. General information

NPI: 1265229892
Provider Name (Legal Business Name): LAURA BROOKE BENNINGTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2025
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WHEELING AVE
GLEN DALE WV
26038-1660
US

IV. Provider business mailing address

53770 CASH RIDGE RD
SHADYSIDE OH
43947-9775
US

V. Phone/Fax

Practice location:
  • Phone: 304-845-3211
  • Fax:
Mailing address:
  • Phone: 740-391-5859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number124382
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: