Provider Demographics
NPI:1942220959
Name:BENNETT, TAMMY RENE (NP)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:RENE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 FAIRFIELD AVE STE 569
Mailing Address - Street 2:OFFICE OF PUBLIC HEALTH
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4331
Mailing Address - Country:US
Mailing Address - Phone:318-676-7483
Mailing Address - Fax:318-676-7560
Practice Address - Street 1:1525 FAIRFIELD AVE STE 569
Practice Address - Street 2:OFFICE OF PUBLIC HEALTH
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4331
Practice Address - Country:US
Practice Address - Phone:318-676-7483
Practice Address - Fax:318-676-7560
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN072119363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1435074Medicaid