Provider Demographics
NPI:1891838041
Name:BENNETT, AMANDA RENEE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RENEE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 E DIAMOND AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47711-3716
Mailing Address - Country:US
Mailing Address - Phone:812-424-5116
Mailing Address - Fax:
Practice Address - Street 1:580 E DIAMOND AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47711-3716
Practice Address - Country:US
Practice Address - Phone:812-424-5116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN67000252A183700000X
237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200331140AMedicaid
IN1168390004Medicare ID - Type Unspecified