Provider Demographics
NPI:1740218791
Name:BENNETT, LISA M (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:BENNETT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:RIEDEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1578 E 59TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-8006
Mailing Address - Country:US
Mailing Address - Phone:248-505-2707
Mailing Address - Fax:
Practice Address - Street 1:4200 E SKELLY DR STE 100
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3235
Practice Address - Country:US
Practice Address - Phone:422-191-8528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704205789367500000X
OHRN-324508367500000X
OKR0134240367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKR0134240OtherOKLAHOMA BOARD OF NURSING
MI4704205789OtherMICHIGAN BOARD OF NURSING
OK200879670AMedicaid