Provider Demographics
NPI:1134254014
Name:BENNER, ANDREA LORRAINE (PT)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:LORRAINE
Last Name:BENNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23978 JOHNSON ST NE
Mailing Address - Street 2:
Mailing Address - City:EAST BETHEL
Mailing Address - State:MN
Mailing Address - Zip Code:55005-9874
Mailing Address - Country:US
Mailing Address - Phone:763-434-1188
Mailing Address - Fax:
Practice Address - Street 1:701 DELLWOOD ST S
Practice Address - Street 2:MAIL ROUTE 71000
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1920
Practice Address - Country:US
Practice Address - Phone:763-689-7716
Practice Address - Fax:763-689-7716
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6999225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist