Provider Demographics
NPI:1235769365
Name:CLARK-BENNETT, INDIA D
Entity Type:Individual
Prefix:MS
First Name:INDIA
Middle Name:D
Last Name:CLARK-BENNETT
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 1:715 SUNNINGDALE DR
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-1240
Mailing Address - Country:US
Mailing Address - Phone:734-716-3894
Mailing Address - Fax:
Practice Address - Street 1:715 SUNNINGDALE DR
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-1240
Practice Address - Country:US
Practice Address - Phone:734-716-3894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703119508164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse