Provider Demographics
NPI:1033479696
Name:MELLO, BETHANY JOY (NP-C)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:JOY
Last Name:MELLO
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 1:951 E PLAZA DR STE 170
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6569
Mailing Address - Country:US
Mailing Address - Phone:208-939-3505
Mailing Address - Fax:
Practice Address - Street 1:951 E PLAZA DR STE 170
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6569
Practice Address - Country:US
Practice Address - Phone:208-939-3505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1639A363LF0000X
ID51084163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse