Provider Demographics
NPI:1699462952
Name:BENNETT, LORI ELIZABETH-FONSECA (RDN, LDN)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:ELIZABETH-FONSECA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:ELIZABETH
Other - Last Name:FONSECA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:141 TWIN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:RACELAND
Mailing Address - State:LA
Mailing Address - Zip Code:70394-2761
Mailing Address - Country:US
Mailing Address - Phone:985-537-2666
Mailing Address - Fax:
Practice Address - Street 1:1978 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70363-7055
Practice Address - Country:US
Practice Address - Phone:985-873-1310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3438133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered