Healthcare Provider Details

I. General information

NPI: 1407114085
Provider Name (Legal Business Name): JENNIFER LYNN BENDER-STAFFORD FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 BIRCH RUN RD STE D
BIRCH RUN MI
48415
US

IV. Provider business mailing address

PO BOX 779
TAWAS CITY MI
48764-0779
US

V. Phone/Fax

Practice location:
  • Phone: 989-624-1575
  • Fax: 989-624-1507
Mailing address:
  • Phone: 989-624-1575
  • Fax: 989-624-1507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704264079
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704264079
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: