Provider Demographics
NPI:1316056005
Name:BENNETT, LORI JOY (MS FNP)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:JOY
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MS FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2364 BISHOP AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-2248
Mailing Address - Country:US
Mailing Address - Phone:734-647-1636
Mailing Address - Fax:734-763-9634
Practice Address - Street 1:2364 BISHOP AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2248
Practice Address - Country:US
Practice Address - Phone:734-647-1636
Practice Address - Fax:734-763-9634
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47041134489363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4110360Medicaid
MI5008664290OtherBCBS