Basic Information
Provider Information | |||||||||
NPI: | 1386033041 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KING | ||||||||
FirstName: | BETHANY | ||||||||
MiddleName: | JILL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ROSS | ||||||||
OtherFirstName: | BETHANY | ||||||||
OtherMiddleName: | JILL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN, CDE | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7261 MERCY RD | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681242311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4023986255 | ||||||||
FaxNumber: | 4028298513 | ||||||||
Practice Location | |||||||||
Address1: | 5002 UNDERWOOD AVE | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681322236 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4027083894 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/20/2015 | ||||||||
LastUpdateDate: | 01/20/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | 098438 | IA | Y |   | Nursing Service Providers | Registered Nurse | Diabetes Educator |
No ID Information.