Provider Demographics
NPI:1376733758
Name:BETHEA, BRIDGET DENISE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:DENISE
Last Name:BETHEA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 748860
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374
Mailing Address - Country:US
Mailing Address - Phone:623-433-0106
Mailing Address - Fax:623-535-0741
Practice Address - Street 1:2840 N DYSART RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2338
Practice Address - Country:US
Practice Address - Phone:623-536-5310
Practice Address - Fax:401-652-9787
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169131363LF0000X
NY335325-1363LF0000X
GARN221907363LP2300X
AZAP5151363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ873862Medicaid
AZ873862Medicaid
AZAP5151OtherAZ LIC
SCNP2090Medicaid
GA202I505534Medicare PIN
AZ873862Medicaid