Basic Information
Provider Information | |||||||||
NPI: | 1942655865 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BENNETT | ||||||||
FirstName: | NICOLA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3400 E RACINE ST | ||||||||
Address2: |   | ||||||||
City: | JANESVILLE | ||||||||
State: | WI | ||||||||
PostalCode: | 535462344 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083738000 | ||||||||
FaxNumber: | 6083738067 | ||||||||
Practice Location | |||||||||
Address1: | 3400 E RACINE ST | ||||||||
Address2: |   | ||||||||
City: | JANESVILLE | ||||||||
State: | WI | ||||||||
PostalCode: | 535462344 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083738000 | ||||||||
FaxNumber: | 6083738067 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2016 | ||||||||
LastUpdateDate: | 11/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209.014255 | IL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LA2200X | 209.014255 | IL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 209.014255 | IL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363L00000X | 6958-33 | WI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 1942655865 | 05 | WI |   | MEDICAID |