Provider Demographics
NPI:1851490874
Name:BENNETT, MICHELE L (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:L
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 W WORKS ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-4213
Mailing Address - Country:US
Mailing Address - Phone:307-673-6100
Mailing Address - Fax:307-673-1975
Practice Address - Street 1:248 W WORKS ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-4213
Practice Address - Country:US
Practice Address - Phone:307-673-6100
Practice Address - Fax:307-673-1975
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6086A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY113791300Medicaid
WY313726OtherBLUE CROSS/BLUE SHIELD
WYP00239528Medicare PIN
WY113791300Medicaid
WY20376Medicare PIN