Provider Demographics
NPI:1265772743
Name:DUYSER, BETHANY SOULE (RN, APN)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:SOULE
Last Name:DUYSER
Suffix:
Gender:F
Credentials:RN, APN
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:GILLAN
Other - Last Name:SOULE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:650 W BUCKINGHAM PL
Mailing Address - Street 2:APT. 1S
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2826
Mailing Address - Country:US
Mailing Address - Phone:773-904-7771
Mailing Address - Fax:
Practice Address - Street 1:650 W BUCKINGHAM PL
Practice Address - Street 2:APT. 1S
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2826
Practice Address - Country:US
Practice Address - Phone:773-904-7771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010113363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner