Provider Demographics
NPI:1407114085
Name:BENDER-STAFFORD, JENNIFER LYNN (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:BENDER-STAFFORD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48764-0779
Mailing Address - Country:US
Mailing Address - Phone:989-624-1575
Mailing Address - Fax:989-624-1507
Practice Address - Street 1:9900 BIRCH RUN RD STE D
Practice Address - Street 2:
Practice Address - City:BIRCH RUN
Practice Address - State:MI
Practice Address - Zip Code:48415
Practice Address - Country:US
Practice Address - Phone:989-624-1575
Practice Address - Fax:989-624-1507
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704264079363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI381893324OtherBLUE CROSS BLUE SHIELD
MI0871972Medicare PIN