Provider Demographics
NPI:1003917774
Name:BENNETT, CHRISTINA LYNN (CNM)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINA
Middle Name:LYNN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MS
Other - First Name:CHRISTINA
Other - Middle Name:LYNN DIX
Other - Last Name:JACKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:1931 BROWN ST STE A
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-4206
Mailing Address - Country:US
Mailing Address - Phone:765-425-7454
Mailing Address - Fax:
Practice Address - Street 1:1931 BROWN ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-4206
Practice Address - Country:US
Practice Address - Phone:765-646-8247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN72000043A363LW0102X, 363LX0001X, 367A00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200531440Medicaid
IN200272370Medicaid