Provider Demographics
NPI:1619789252
Name:KIRILLOV, BETHANY ELLEN (CDM)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:ELLEN
Last Name:KIRILLOV
Suffix:
Gender:F
Credentials:CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 E SILVER FOX LN
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-3846
Mailing Address - Country:US
Mailing Address - Phone:907-521-5572
Mailing Address - Fax:
Practice Address - Street 1:525 E SILVER FOX LN
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-3846
Practice Address - Country:US
Practice Address - Phone:907-521-5572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-21
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK232272176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife