1760477947 NPI number — LISA G BENNETT FNP

Table of content: RICHARD WAYNE WOOTEN M.A. (NPI 1679743389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760477947 NPI number — LISA G BENNETT FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNETT
Provider First Name:
LISA
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SAWYERS
Provider Other First Name:
LISA
Provider Other Middle Name:
G
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760477947
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
252 RURAL ACRES DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BECKLEY
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25801-3503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-253-2638
Provider Business Mailing Address Fax Number:
304-252-1720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BECKLEY
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25801-6046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-252-8551
Provider Business Practice Location Address Fax Number:
304-461-1105
Provider Enumeration Date:
09/14/2005

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: 363LF0000X , with the licence number:  52885 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 38100003317 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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