Provider Demographics
NPI:1912637109
Name:SHORTALL, BETHANNIE J (RN)
Entity type:Individual
Prefix:MS
First Name:BETHANNIE
Middle Name:J
Last Name:SHORTALL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1984 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14571-9797
Mailing Address - Country:US
Mailing Address - Phone:585-664-8975
Mailing Address - Fax:
Practice Address - Street 1:1984 MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERPORT
Practice Address - State:NY
Practice Address - Zip Code:14571-9797
Practice Address - Country:US
Practice Address - Phone:585-664-8975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY682264-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse