Provider Demographics
NPI:1578117081
Name:BENNETT, ALI (LPN)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:BENNETT
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 1:11811 GALLOWAY LOOP
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:670 W FIREWEED LN STE 160
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2561
Practice Address - Country:US
Practice Address - Phone:907-770-0862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK136038164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse