Provider Demographics
NPI:1073819637
Name:STOCKARD, BETHANY
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:STOCKARD
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 1:4065 LAPLANTE RD
Mailing Address - Street 2:
Mailing Address - City:MONCLOVA
Mailing Address - State:OH
Mailing Address - Zip Code:43542
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4065 LAPLANTE RD
Practice Address - Street 2:
Practice Address - City:MONCLOVA
Practice Address - State:OH
Practice Address - Zip Code:43542-9540
Practice Address - Country:US
Practice Address - Phone:419-508-6159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH121816164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse