Provider Demographics
NPI:1063952612
Name:PENROD, BETHANY LYN
Entity type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:LYN
Last Name:PENROD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:LYN
Other - Last Name:DEVINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 WOODY DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:13167-4184
Mailing Address - Country:US
Mailing Address - Phone:315-744-3779
Mailing Address - Fax:
Practice Address - Street 1:40 WOODY DR
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:NY
Practice Address - Zip Code:13167-4184
Practice Address - Country:US
Practice Address - Phone:315-744-3779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist