Provider Demographics
NPI:1609916394
Name:BENNETT, ANNABELLE L (NP)
Entity Type:Individual
Prefix:
First Name:ANNABELLE
Middle Name:L
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ANNABELLE
Other - Middle Name:L
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1716 HARTFORD ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2173
Mailing Address - Country:US
Mailing Address - Phone:765-742-1567
Mailing Address - Fax:765-429-6961
Practice Address - Street 1:1716 HARTFORD ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2173
Practice Address - Country:US
Practice Address - Phone:765-742-1567
Practice Address - Fax:765-429-6961
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002238A363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71002238AOtherST. LICENSE
IN2008455550Medicaid