Provider Demographics
NPI:1508843590
Name:BENTLEY, KATRINA K (PHD, CNS, NP-C)
Entity Type:Individual
Prefix:MS
First Name:KATRINA
Middle Name:K
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:PHD, CNS, NP-C
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 145
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-0145
Mailing Address - Country:US
Mailing Address - Phone:208-983-5535
Mailing Address - Fax:208-983-5575
Practice Address - Street 1:365 CENTER ROAD
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-1917
Practice Address - Country:US
Practice Address - Phone:208-983-5535
Practice Address - Fax:208-983-5575
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-527A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1343738Medicare ID - Type Unspecified
IDR81319Medicare UPIN