Provider Demographics
NPI:1164817656
Name:BENNINGTON, MICHELE
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:BENNINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7720 LIMA RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-2163
Mailing Address - Country:US
Mailing Address - Phone:260-482-8503
Mailing Address - Fax:
Practice Address - Street 1:7720 LIMA RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-2163
Practice Address - Country:US
Practice Address - Phone:260-482-8503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001413A237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist