Provider Demographics
NPI:1396010427
Name:GILLEY, BETHANY JOY RUDGE
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:JOY RUDGE
Last Name:GILLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:BETHANY
Other - Middle Name:JOY
Other - Last Name:RUDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:465 N BELAIR RD
Mailing Address - Street 2:SUITE 1 B
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3188
Mailing Address - Country:US
Mailing Address - Phone:706-868-3100
Mailing Address - Fax:
Practice Address - Street 1:465 N BELAIR RD
Practice Address - Street 2:SUITE 1 B
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3188
Practice Address - Country:US
Practice Address - Phone:706-868-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2098363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant