Provider Demographics
NPI:1255931093
Name:BENNETT, SHANNA ANN (RD)
Entity type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:ANN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 ENCORE WAY
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72019-8896
Mailing Address - Country:US
Mailing Address - Phone:501-219-7770
Mailing Address - Fax:
Practice Address - Street 1:1901 ENCORE WAY
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72019-8896
Practice Address - Country:US
Practice Address - Phone:501-219-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2000133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered