=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619453040
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE ANN BENNINGTON DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2018
-----------------------------------------------------
Last Update Date | 03/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 W LAKEWAY RD STE 700
-----------------------------------------------------
City | GILLETTE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82718-6346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-387-9850
-----------------------------------------------------
Fax | 307-387-9890
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 W LAKEWAY RD STE 1004
-----------------------------------------------------
City | GILLETTE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82718-6349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-387-9850
-----------------------------------------------------
Fax | 307-387-9890
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 8352
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 036167028
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 17508A
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------