Provider Demographics
NPI:1417248311
Name:BENNETT, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name: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 1:401 S 23RD ST
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401-3725
Mailing Address - Country:US
Mailing Address - Phone:307-347-6165
Mailing Address - Fax:307-347-6166
Practice Address - Street 1:401 S 23RD ST
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401-3725
Practice Address - Country:US
Practice Address - Phone:307-347-6165
Practice Address - Fax:307-347-6166
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106352907Medicaid
WY106352908Medicaid