Provider Demographics
NPI:1427722727
Name:BETHUNE, IVORY ROCHELLE
Entity type:Individual
Prefix:
First Name:IVORY
Middle Name:ROCHELLE
Last Name:BETHUNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IVORY
Other - Middle Name:ROCHELLE
Other - Last Name:BETHUNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5949 LAWNDALE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-1209
Mailing Address - Country:US
Mailing Address - Phone:215-439-1435
Mailing Address - Fax:
Practice Address - Street 1:5949 LAWNDALE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-1209
Practice Address - Country:US
Practice Address - Phone:215-439-1435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver