Provider Demographics
NPI:1700302528
Name:BENNETT, AMANDA ELIZABETH (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:BENNETT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ELIZABETH
Other - Last Name:THELEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:517-253-6320
Mailing Address - Fax:517-364-6208
Practice Address - Street 1:102 SOUTH THRID STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:CARSON CITY
Practice Address - State:MI
Practice Address - Zip Code:48811
Practice Address - Country:US
Practice Address - Phone:989-584-1308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704282874363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily