Provider Demographics
NPI:1932462454
Name:BENNETT, LYNN PHYLLIS (RN)
Entity Type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:PHYLLIS
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11587 LAUREL LAKE SQ
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6074
Mailing Address - Country:US
Mailing Address - Phone:571-224-5426
Mailing Address - Fax:
Practice Address - Street 1:11587 LAUREL LAKE SQ
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6074
Practice Address - Country:US
Practice Address - Phone:571-224-5426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001105791163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse