Provider Demographics
NPI:1336848381
Name:REYNOLDS, BETHANY E (NP)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:E
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:E
Other - Last Name:NELMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2605 N LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2705 N LEBANON ST STE 342
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-8621
Practice Address - Country:US
Practice Address - Phone:765-485-8740
Practice Address - Fax:765-485-8749
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28207345A163W00000X
IN71013671A363LF0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300073000Medicaid