=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629408497
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHERILYN JO BENNETT APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2013
-----------------------------------------------------
Last Update Date | 02/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1341 W 6TH ST
-----------------------------------------------------
City | WALDRON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72958-7642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-637-1181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1683 JENKINS RD PO BOX 2031
-----------------------------------------------------
City | WALDRON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72958-8061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-637-1181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | R86370
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | A003998
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------