Provider Demographics
NPI:1326367715
Name:ROSE, BETHANI K (DO)
Entity Type:Individual
Prefix:
First Name:BETHANI
Middle Name:K
Last Name:ROSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 KY ROUTE 321 STE 3
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-9097
Mailing Address - Country:US
Mailing Address - Phone:606-886-8546
Mailing Address - Fax:
Practice Address - Street 1:1709 KY ROUTE 321 STE 3
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-9097
Practice Address - Country:US
Practice Address - Phone:606-886-8546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY03500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine