Provider Demographics
NPI:1649344227
Name:BENNISON, LETA MARIE (CNP)
Entity type:Individual
Prefix:
First Name:LETA
Middle Name:MARIE
Last Name:BENNISON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:415 N 26TH ST STE 202
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2856
Practice Address - Country:US
Practice Address - Phone:765-448-8639
Practice Address - Fax:765-448-8156
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002721A363L00000X
MI4704155800363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000582659OtherANTHEM PROVIDER NUMBER
IN200911130Medicaid
IN000000582659OtherANTHEM PROVIDER NUMBER
INQ73969Medicare UPIN
IN815500L9Medicare PIN
IN815500IIMedicare PIN