Provider Demographics
NPI:1114644663
Name:RACINE, BETHANY (LPN)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:RACINE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:GILBERTVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01031-9704
Mailing Address - Country:US
Mailing Address - Phone:774-230-4983
Mailing Address - Fax:
Practice Address - Street 1:72 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:GILBERTVILLE
Practice Address - State:MA
Practice Address - Zip Code:01031-9704
Practice Address - Country:US
Practice Address - Phone:774-230-4983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN101038164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse