Provider Demographics
NPI:1962002659
Name:MIRKA, BETHANY
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:MIRKA
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 1:3000 RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:OSTRANDER
Mailing Address - State:OH
Mailing Address - Zip Code:43061-9406
Mailing Address - Country:US
Mailing Address - Phone:740-666-2222
Mailing Address - Fax:
Practice Address - Street 1:3000 RUSSELL RD
Practice Address - Street 2:
Practice Address - City:OSTRANDER
Practice Address - State:OH
Practice Address - Zip Code:43061-9406
Practice Address - Country:US
Practice Address - Phone:740-666-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant