Provider Demographics
NPI:1639874340
Name:EDGE, BETHANY NICOLE CRAFT (RDN)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:NICOLE CRAFT
Last Name:EDGE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6002 OLD CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23605-2128
Mailing Address - Country:US
Mailing Address - Phone:909-971-7881
Mailing Address - Fax:
Practice Address - Street 1:12650 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4316
Practice Address - Country:US
Practice Address - Phone:909-971-7881
Practice Address - Fax:757-875-7807
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA86175532133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered