Provider Demographics
NPI:1366952657
Name:BENNETT, ANN (IBCLC)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 LOMITA VERDE CIR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-4208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2113 HIGHLAND RIDGE DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:MD
Practice Address - Zip Code:21131-1217
Practice Address - Country:US
Practice Address - Phone:917-567-5260
Practice Address - Fax:917-567-5260
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L13482174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN