Healthcare Provider Details

I. General information

NPI: 1164817656
Provider Name (Legal Business Name): MICHELE BENNINGTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7720 LIMA RD
FORT WAYNE IN
46818-2163
US

IV. Provider business mailing address

7720 LIMA RD
FORT WAYNE IN
46818-2163
US

V. Phone/Fax

Practice location:
  • Phone: 260-482-8503
  • Fax:
Mailing address:
  • Phone: 260-482-8503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number17001413A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: