Provider Demographics
NPI:1326191230
Name:KELLEY, BETHANIE C (WHNP)
Entity Type:Individual
Prefix:MRS
First Name:BETHANIE
Middle Name:C
Last Name:KELLEY
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12801 IRON BRIDGE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-1669
Mailing Address - Country:US
Mailing Address - Phone:804-706-5827
Mailing Address - Fax:804-706-5819
Practice Address - Street 1:12801 IRON BRIDGE RD STE 100
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-1669
Practice Address - Country:US
Practice Address - Phone:804-706-5827
Practice Address - Fax:804-706-5819
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166833363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004975189Medicaid
VA1326191230Medicaid
VA600699119Medicare ID - Type Unspecified
VA022589J52Medicare PIN