Provider Demographics
NPI:1508230822
Name:BETHEA, ANITA (LVN)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:BETHEA
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 OLD HIGHWAY 13
Mailing Address - Street 2:
Mailing Address - City:PINOLA
Mailing Address - State:MS
Mailing Address - Zip Code:39149-3813
Mailing Address - Country:US
Mailing Address - Phone:601-808-1914
Mailing Address - Fax:601-847-2086
Practice Address - Street 1:168 OLD HIGHWAY 13
Practice Address - Street 2:
Practice Address - City:PINOLA
Practice Address - State:MS
Practice Address - Zip Code:39149-3813
Practice Address - Country:US
Practice Address - Phone:601-808-1914
Practice Address - Fax:601-847-2086
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP319589164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse