1407114085 NPI number — MRS. JENNIFER LYNN BENDER-STAFFORD FNP-BC

Table of content: MRS. JENNIFER LYNN BENDER-STAFFORD FNP-BC (NPI 1407114085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407114085 NPI number — MRS. JENNIFER LYNN BENDER-STAFFORD FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENDER-STAFFORD
Provider First Name:
JENNIFER
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407114085
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 779
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAWAS CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48764-0779
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-624-1575
Provider Business Mailing Address Fax Number:
989-624-1507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9900 BIRCH RUN RD STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIRCH RUN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-624-1575
Provider Business Practice Location Address Fax Number:
989-624-1507
Provider Enumeration Date:
05/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  4704264079 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 4704264079 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 381893324 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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