Provider Demographics
NPI:1700477064
Name:DEFORD, BETHANY M (RN, MPH, BSN)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:M
Last Name:DEFORD
Suffix:
Gender:F
Credentials:RN, MPH, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 PRESIDENT ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4050 BRIDGE VIEW DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-7488
Practice Address - Country:US
Practice Address - Phone:908-892-6189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC244731163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse