Provider Demographics
NPI:1184678716
Name:BENNETT, MIRANDA L (APN)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:L
Last Name:BENNETT
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:L
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APN
Mailing Address - Street 1:1211 S GLOSTER ST STE A
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6548
Mailing Address - Country:US
Mailing Address - Phone:662-767-4200
Mailing Address - Fax:662-767-4204
Practice Address - Street 1:100 BAPTIST MEMORIAL CIR STE 330
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-4477
Practice Address - Country:US
Practice Address - Phone:662-767-4200
Practice Address - Fax:662-767-4204
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA810433363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3341953Medicare PIN