Provider Demographics
NPI:1780676031
Name:BOTNICK, BETH S (NP)
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:S
Last Name:BOTNICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:BETH
Other - Middle Name:S
Other - Last Name:THRASHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1430 STEPHENS DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3716
Mailing Address - Country:US
Mailing Address - Phone:404-403-3326
Mailing Address - Fax:
Practice Address - Street 1:1430 STEPHENS DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3716
Practice Address - Country:US
Practice Address - Phone:404-403-3326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2011-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN118785363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ22887Medicare UPIN