Provider Demographics
NPI:1487051827
Name:BENNETT, TAMIE (ADULT GERONTOLOGY NP)
Entity type:Individual
Prefix:
First Name:TAMIE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:ADULT GERONTOLOGY NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 E WAUPUN ST
Mailing Address - Street 2:
Mailing Address - City:OAKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53065-9746
Mailing Address - Country:US
Mailing Address - Phone:920-583-2631
Mailing Address - Fax:
Practice Address - Street 1:227 E WAUPUN ST
Practice Address - Street 2:
Practice Address - City:OAKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53065-9746
Practice Address - Country:US
Practice Address - Phone:920-583-2631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5949-33363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWISCONSINMedicaid
WISCONSINMedicare PIN