Provider Demographics
NPI:1962038307
Name:BETHI, THANMAYIE
Entity Type:Individual
Prefix:
First Name:THANMAYIE
Middle Name:
Last Name:BETHI
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 1:4112 E PONCE DE LEON AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-8106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4112 E PONCE DE LEON AVE
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:GA
Practice Address - Zip Code:30021-8106
Practice Address - Country:US
Practice Address - Phone:404-296-7133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA246736363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily