Provider Demographics
NPI:1770135501
Name:BENNETT, LISA LYNN
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:LYNN
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 1:337 HIGHWAY 27 N
Mailing Address - Street 2:
Mailing Address - City:TYLERTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:39667-7933
Mailing Address - Country:US
Mailing Address - Phone:601-522-3582
Mailing Address - Fax:
Practice Address - Street 1:1320 N MORRISON BLVD
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-2242
Practice Address - Country:US
Practice Address - Phone:985-551-5155
Practice Address - Fax:985-551-5222
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator