Individual
NICOLE ANDREA BENNETT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PMHNP-BC
Contact information
Practice address
2 TERMINAL DR STE 8, EAST ALTON, IL 62024-2294
(618) 259-0365
(618) 259-2495
Mailing address
2 TERMINAL DR STE 8, EAST ALTON, IL 62024-2294
(618) 259-0365
(618) 259-2495
Taxonomy
Speciality
Code
Description
License number
State
163WP0808X
Psychiatric/Mental Health Registered Nurse
2018036588
MO
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
209030085
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
041470020
RN
IL
01
—
2018036588
RN
MO
Enumeration date
01/26/2021
Last updated
08/07/2024
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