Provider Demographics
NPI:1871007716
Name:BENNETT, MOLLY NICHOLE (LPN)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:NICHOLE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 E SOUTH H ST
Mailing Address - Street 2:
Mailing Address - City:GAS CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46933-1848
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:729 W 35TH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-4215
Practice Address - Country:US
Practice Address - Phone:765-674-3371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27067474A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse