Provider Demographics
NPI:1376674317
Name:HERTWECK, BETHANNE (LPN)
Entity Type:Individual
Prefix:
First Name:BETHANNE
Middle Name:
Last Name:HERTWECK
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 1:10972 TABERG FLORENCE RD
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13316-4018
Mailing Address - Country:US
Mailing Address - Phone:315-245-2391
Mailing Address - Fax:
Practice Address - Street 1:2 TERRITORY RD
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-9304
Practice Address - Country:US
Practice Address - Phone:315-829-8700
Practice Address - Fax:315-892-8730
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24674-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse