Provider Demographics
NPI:1245654771
Name:BENNETT, LAURA (APN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:135 HENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-1549
Mailing Address - Country:US
Mailing Address - Phone:609-540-7207
Mailing Address - Fax:
Practice Address - Street 1:1700 N BROAD ST STE 4
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-3429
Practice Address - Country:US
Practice Address - Phone:215-204-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-04
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00482500363L00000X, 363LF0000X
PASP029186363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner