Provider Demographics
NPI:1285693960
Name:DEKONINCK, BETH ANN (NP-C)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:ANN
Last Name:DEKONINCK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 E MEADOW RD STE 6
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-3469
Mailing Address - Country:US
Mailing Address - Phone:219-204-1854
Mailing Address - Fax:
Practice Address - Street 1:207 E MEADOW RD STE 6
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-3469
Practice Address - Country:US
Practice Address - Phone:219-204-1854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000315A363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200169950Medicaid
IN000000372024OtherANTHEM PROVIDER NUMBER
IN9397614OtherPHCS PID NUMBER
IN815500X6Medicare PIN
IN069320DMedicare PIN
IN9397614OtherPHCS PID NUMBER
INS53882Medicare UPIN