Provider Demographics
NPI:1053502260
Name:MORTIMER, BEVERLY JO (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:JO
Last Name:MORTIMER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1759
Mailing Address - Country:US
Mailing Address - Phone:270-780-2497
Mailing Address - Fax:270-783-3750
Practice Address - Street 1:1330 N RACE ST
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3465
Practice Address - Country:US
Practice Address - Phone:270-629-5111
Practice Address - Fax:270-783-3760
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5266P363LF0000X
KY3005266363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100072050Medicaid
KYK024151Medicare PIN
KY00388002Medicare PIN