Provider Demographics
NPI:1871708719
Name:BENNETT, NANCY MARIE (LPN)
Entity type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:MARIE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 MAIN ST
Mailing Address - Street 2:PO. BOX 319
Mailing Address - City:BLOOMINGBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43106
Mailing Address - Country:US
Mailing Address - Phone:740-437-7539
Mailing Address - Fax:
Practice Address - Street 1:90 MAIN ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGBURG
Practice Address - State:OH
Practice Address - Zip Code:43106
Practice Address - Country:US
Practice Address - Phone:740-437-7539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.095885164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2499701Medicaid