Provider Demographics
NPI:1275032849
Name:WOLTER, BETHANY (BSN, RN, CDE)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:WOLTER
Suffix:
Gender:F
Credentials:BSN, RN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 S WAVERLY RD STE A
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7906
Mailing Address - Country:US
Mailing Address - Phone:616-394-3320
Mailing Address - Fax:616-994-0282
Practice Address - Street 1:175 S WAVERLY RD STE A
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7906
Practice Address - Country:US
Practice Address - Phone:616-394-3320
Practice Address - Fax:616-994-0282
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704269471163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator