Healthcare Provider Details

I. General information

NPI: 1609916394
Provider Name (Legal Business Name): ANNABELLE L BENNETT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNABELLE L MILLER

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 HARTFORD ST
LAFAYETTE IN
47904-2173
US

IV. Provider business mailing address

1716 HARTFORD ST
LAFAYETTE IN
47904-2173
US

V. Phone/Fax

Practice location:
  • Phone: 765-742-1567
  • Fax: 765-429-6961
Mailing address:
  • Phone: 765-742-1567
  • Fax: 765-429-6961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71002238A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71002238A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: