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Individual
LETA MARIE BENNISON
Active
Individual
LETA MARIE BENNISON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CNP
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
4704155800
MI
363L00000X
Nurse Practitioner
Primary
71002721A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000582659
ANTHEM PROVIDER NUMBER
IN
05
—
200911130
—
IN
Enumeration date
11/17/2006
Last updated
07/23/2012
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