Provider Demographics
NPI:1679163372
Name:BENNETT, NICOLE ANDREA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANDREA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 TERMINAL DR STE 8
Mailing Address - Street 2:
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-2294
Mailing Address - Country:US
Mailing Address - Phone:618-259-0365
Mailing Address - Fax:618-259-2495
Practice Address - Street 1:2 TERMINAL DR STE 8
Practice Address - Street 2:
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-2294
Practice Address - Country:US
Practice Address - Phone:618-259-0365
Practice Address - Fax:618-259-2495
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018036588163WP0808X
IL209030085363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041470020OtherRN
MO2018036588OtherRN