Provider Demographics
NPI:1558118141
Name:BEASLEY, BETHANY
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1576 HAGIN STILL RD
Mailing Address - Street 2:
Mailing Address - City:DOERUN
Mailing Address - State:GA
Mailing Address - Zip Code:31744-5301
Mailing Address - Country:US
Mailing Address - Phone:229-881-4611
Mailing Address - Fax:
Practice Address - Street 1:2701 MEREDYTH DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-2267
Practice Address - Country:US
Practice Address - Phone:229-883-7010
Practice Address - Fax:229-903-1585
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN278891363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty