Provider Demographics
NPI:1639687858
Name:GAULTNEY, BETHANY (APRN)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:GAULTNEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 HORIZON TRL
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-4415
Mailing Address - Country:US
Mailing Address - Phone:843-603-4800
Mailing Address - Fax:
Practice Address - Street 1:40 OKATIE CTR BLVD STE 215
Practice Address - Street 2:
Practice Address - City:OKATIE
Practice Address - State:SC
Practice Address - Zip Code:29909-7507
Practice Address - Country:US
Practice Address - Phone:256-453-6074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN272112363L00000X
SC21590363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner