Provider Demographics
NPI:1538461967
Name:SPRAGUE, BETHANY J
Entity Type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:J
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4622 PALLADIUM PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-8130
Mailing Address - Country:US
Mailing Address - Phone:704-728-9509
Mailing Address - Fax:
Practice Address - Street 1:2632 FINES CREEK DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625
Practice Address - Country:US
Practice Address - Phone:704-880-8665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004963363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily