Provider Demographics
NPI:1396196648
Name:GREEN, BETHANY WESTON
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:WESTON
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:
Other - Last Name:WESTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301 CUMBERLAND ST APT F5
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-1045
Mailing Address - Country:US
Mailing Address - Phone:919-605-5083
Mailing Address - Fax:
Practice Address - Street 1:150 E 42ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-5612
Practice Address - Country:US
Practice Address - Phone:212-661-8139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2016-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340729363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily