Healthcare Provider Details

I. General information

NPI: 1003917774
Provider Name (Legal Business Name): CHRISTINA LYNN BENNETT CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINA LYNN DIX JACKEY CNM

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 BROWN ST
ANDERSON IN
46016-4206
US

IV. Provider business mailing address

1931 BROWN ST STE A
ANDERSON IN
46016-4206
US

V. Phone/Fax

Practice location:
  • Phone: 765-646-8247
  • Fax:
Mailing address:
  • Phone: 765-425-7454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number72000043A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number72000043A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number72000043A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number72000043A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: