Basic Information
| Provider Information | |||||||||
| NPI: | 1962649319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNET | ||||||||
| FirstName: | LEABETH | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1841 MADORA AVE | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826333057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073582846 | ||||||||
| FaxNumber: | 3073585329 | ||||||||
| Practice Location | |||||||||
| Address1: | 1841 MADORA AVE | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826333057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073582846 | ||||||||
| FaxNumber: | 3073585329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2009 | ||||||||
| LastUpdateDate: | 01/07/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA0400X | 21481 | WY | N | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | 163WP0808X | 21481 | WY | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.