Provider Demographics
NPI:1184198509
Name:BETHEL, LAUREN NICOLE
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:NICOLE
Last Name:BETHEL
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 1:466 MANILLA CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:POCA
Mailing Address - State:WA
Mailing Address - Zip Code:25159
Mailing Address - Country:US
Mailing Address - Phone:304-545-1185
Mailing Address - Fax:
Practice Address - Street 1:466 MANILLA CREEK ROAD
Practice Address - Street 2:
Practice Address - City:POCA
Practice Address - State:WV
Practice Address - Zip Code:25159
Practice Address - Country:US
Practice Address - Phone:304-545-1185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer