Provider Demographics
NPI:1558976993
Name:BENNETT, LORENA J
Entity Type:Individual
Prefix:
First Name:LORENA
Middle Name:J
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 1:2630 SAWBURY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-1863
Mailing Address - Country:US
Mailing Address - Phone:614-806-9618
Mailing Address - Fax:
Practice Address - Street 1:2630 SAWBURY BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-1863
Practice Address - Country:US
Practice Address - Phone:614-806-9618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-12
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2573514374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2573514Medicaid