Provider Demographics
NPI:1174799548
Name:BENNETT, KEVIN RICHARD (RN)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:RICHARD
Last Name:BENNETT
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 BOGAR LN
Mailing Address - Street 2:
Mailing Address - City:MIFFLINBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17844-1404
Mailing Address - Country:US
Mailing Address - Phone:570-966-1254
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD STE 240
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-2225
Practice Address - Country:US
Practice Address - Phone:570-524-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN517145L313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility