Provider Demographics
NPI:1962001537
Name:BENNETT, MARIE LOUSELIA
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:LOUSELIA
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 1:22 CHIEF DR
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-5755
Mailing Address - Country:US
Mailing Address - Phone:304-704-0935
Mailing Address - Fax:
Practice Address - Street 1:22 CHIEF DR
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-5755
Practice Address - Country:US
Practice Address - Phone:304-704-0935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant