Provider Demographics
NPI:1497943922
Name:BENNETHUM, DEBORAH S (LPN)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:S
Last Name:BENNETHUM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12277 ELTON ST SW
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:OH
Mailing Address - Zip Code:44662-9636
Mailing Address - Country:US
Mailing Address - Phone:330-309-0119
Mailing Address - Fax:
Practice Address - Street 1:12277 ELTON ST SW
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:OH
Practice Address - Zip Code:44662-9636
Practice Address - Country:US
Practice Address - Phone:330-309-0119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 084536164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse