Provider Demographics
NPI:1790320737
Name:TODD, BETH ANN
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ANN
Last Name:TODD
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 1:1068 OLYMPIA LN
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-4497
Mailing Address - Country:US
Mailing Address - Phone:815-540-6339
Mailing Address - Fax:
Practice Address - Street 1:1068 OLYMPIA LN
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4497
Practice Address - Country:US
Practice Address - Phone:815-540-6339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.374311163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000000000OtherDO NOT HAVE