Provider Demographics
NPI:1982213609
Name:MCINNIS, BETHANY ROSE (APRN)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:ROSE
Last Name:MCINNIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 WESTERN AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2458
Mailing Address - Country:US
Mailing Address - Phone:207-661-0200
Mailing Address - Fax:
Practice Address - Street 1:181 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:ME
Practice Address - Zip Code:04268-5664
Practice Address - Country:US
Practice Address - Phone:207-744-6117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP201234363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily