Basic Information
| Provider Information | |||||||||
| NPI: | 1700981883 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RATLIFF | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | RUTH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ULDRICH | ||||||||
| OtherFirstName: | BETHANY | ||||||||
| OtherMiddleName: | RUTH | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 617 RIVER ST | ||||||||
| Address2: | |||||||||
| City: | GASSAWAY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 266241137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043648941 | ||||||||
| FaxNumber: | 3043648943 | ||||||||
| Practice Location | |||||||||
| Address1: | 617 RIVER ST | ||||||||
| Address2: | |||||||||
| City: | GASSAWAY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 266241137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043648941 | ||||||||
| FaxNumber: | 3043648943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 06/23/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| 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 | 363LF0000X | 48777 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3810012243 | 05 | WV | MEDICAID |