Provider Demographics
NPI:1396201885
Name:BETHEA, DOMINIQUE K (NP)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:K
Last Name:BETHEA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 OLD NORCROSS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4980
Mailing Address - Country:US
Mailing Address - Phone:770-339-1387
Mailing Address - Fax:770-962-7868
Practice Address - Street 1:771 OLD NORCROSS RD STE 200
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4980
Practice Address - Country:US
Practice Address - Phone:770-339-1387
Practice Address - Fax:770-962-7868
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN281107363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily