Provider Demographics
NPI:1003422163
Name:BHETWAL, KUSUM
Entity Type:Individual
Prefix:
First Name:KUSUM
Middle Name:
Last Name:BHETWAL
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 1:12804 WESTIN ESTATES DRIVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059
Mailing Address - Country:US
Mailing Address - Phone:804-382-5458
Mailing Address - Fax:
Practice Address - Street 1:12804 WESTIN ESTATES DRIVE
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059
Practice Address - Country:US
Practice Address - Phone:804-382-5458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024179682363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily