Provider Demographics
NPI:1316353238
Name:BENNETT, LOLA
Entity type:Individual
Prefix:
First Name:LOLA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LOLA
Other - Middle Name:J
Other - Last Name:BENJAMIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:1115 CROES AVE
Mailing Address - Street 2:B2
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10472-4533
Mailing Address - Country:US
Mailing Address - Phone:917-548-7532
Mailing Address - Fax:718-904-8320
Practice Address - Street 1:1000 PELHAM PKWY S
Practice Address - Street 2:LTHHCP
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1003
Practice Address - Country:US
Practice Address - Phone:718-409-7992
Practice Address - Fax:718-904-8320
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-11
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY405828-1163W00000X
GA174625163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY405828-1OtherREGISTERED NURSE
GA174625OtherREGISTERED NURSE