Provider Demographics
NPI:1396112546
Name:SHIVELY, BETHANY (APRN)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:SHIVELY
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 1:2156 TODDS POINT RD
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40067-6545
Mailing Address - Country:US
Mailing Address - Phone:502-836-1450
Mailing Address - Fax:
Practice Address - Street 1:2156 TODDS POINT ROAD
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:KY
Practice Address - Zip Code:40067
Practice Address - Country:US
Practice Address - Phone:502-836-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009535363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health