Provider Demographics
NPI:1194093807
Name:BETHEL, KENNETH SCOTT (RN, FNP)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:SCOTT
Last Name:BETHEL
Suffix:
Gender:M
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 SIMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-4666
Mailing Address - Country:US
Mailing Address - Phone:574-293-0052
Mailing Address - Fax:574-293-7635
Practice Address - Street 1:236 SIMPSON AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-4666
Practice Address - Country:US
Practice Address - Phone:574-293-0052
Practice Address - Fax:574-293-7635
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28138800A363LF0000X
IN71003875A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201043130Medicaid
IN201043130Medicaid