Provider Demographics
NPI:1588649958
Name:BENNER, JOAN LUCILLE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:LUCILLE
Last Name:BENNER
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:927 CHURCHILL ST W
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6605
Mailing Address - Country:US
Mailing Address - Phone:651-430-8537
Mailing Address - Fax:651-430-4646
Practice Address - Street 1:1500 CURVE CREST BLVD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6040
Practice Address - Country:US
Practice Address - Phone:651-439-1237
Practice Address - Fax:651-439-1547
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN31704207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNE77374Medicare UPIN