Provider Demographics
NPI:1760477947
Name:BENNETT, LISA G (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:G
Last Name:BENNETT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:G
Other - Last Name:SAWYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1602 HARPER RD
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3310
Mailing Address - Country:US
Mailing Address - Phone:304-252-8531
Mailing Address - Fax:304-252-0466
Practice Address - Street 1:1602 HARPER RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3310
Practice Address - Country:US
Practice Address - Phone:304-252-8531
Practice Address - Fax:304-252-0466
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV52885363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV38100003317Medicaid