Provider Demographics
NPI:1972223915
Name:BALL, BETHANY P (NP)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:P
Last Name:BALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MILLER PKWY APT 7206
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-1854
Mailing Address - Country:US
Mailing Address - Phone:662-803-0196
Mailing Address - Fax:
Practice Address - Street 1:117 FOUNTAINS BLVD STE 1
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6317
Practice Address - Country:US
Practice Address - Phone:601-499-1105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905499363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty