Provider Demographics
NPI:1750837969
Name:STAFFORD, BETHANY
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:STAFFORD
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 1:1825 LOGAN AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-1916
Mailing Address - Country:US
Mailing Address - Phone:319-235-3838
Mailing Address - Fax:319-235-5272
Practice Address - Street 1:1825 LOGAN AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1916
Practice Address - Country:US
Practice Address - Phone:319-235-3838
Practice Address - Fax:319-235-5272
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAH-121407363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care