Provider Demographics
NPI:1942220959
Name:BENNETT, TAMMY RENE (NP)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:RENE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:655 SR 333
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-0963
Mailing Address - Country:US
Mailing Address - Phone:318-470-1886
Mailing Address - Fax:
Practice Address - Street 1:1525 FAIRFIELD AVE STE 569
Practice Address - Street 2:OFFICE OF PUBLIC HEALTH
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4331
Practice Address - Country:US
Practice Address - Phone:318-676-7483
Practice Address - Fax:318-676-7560
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2024-05-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LARN072119363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1435074Medicaid