Basic Information
| Provider Information | |||||||||
| NPI: | 1063404127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794308143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432757 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794300002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432757 | ||||||||
| FaxNumber: | 8067432563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | K0417 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | A297 | 01 | NM | TRIWEST | OTHER | 100155840A | 05 | OK | MEDICAID | 117701603 | 05 | TX | MEDICAID | 108429102 | 01 | TX | FIRSTCARE COMMERCIAL | OTHER | 87813G | 01 | TX | BCBS | OTHER | 108429103 | 05 | TX | MEDICAID | 117701602 | 05 | TX | MEDICAID | 83027Z | 01 | TX | HMO BLUE | OTHER | 62147 | 01 | NM | PRESBYTERIAN COMMERCIAL | OTHER | T9668 | 05 | NM | MEDICAID |