=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447759527
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANECE LYNN BENNETT APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2018
-----------------------------------------------------
Last Update Date | 05/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 426 S BLANCHE ST
-----------------------------------------------------
City | MOUNDS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62964-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-745-6894
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25431 TAMMS OLIVE BRANCH RD
-----------------------------------------------------
City | TAMMS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62988-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-270-2366
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 209017228
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------