Provider Demographics
NPI:1790406767
Name:TONGUIS, BETHANY C
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:C
Last Name:TONGUIS
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 1:320 RACETRACK RD NW STE 100A
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1796
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:320 RACETRACK RD NW STE 100A
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1796
Practice Address - Country:US
Practice Address - Phone:850-315-8360
Practice Address - Fax:850-315-4262
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9349846163WX0003X
FLAPRN11022540367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient