Provider Demographics
NPI:1700965076
Name:BAXTER, BETH ANNE (MSN,NP)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ANNE
Last Name:BAXTER
Suffix:
Gender:F
Credentials:MSN,NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 W 1ST ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2384
Mailing Address - Country:US
Mailing Address - Phone:812-323-0971
Mailing Address - Fax:812-323-1285
Practice Address - Street 1:822 W 1ST ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2384
Practice Address - Country:US
Practice Address - Phone:812-323-0971
Practice Address - Fax:812-323-1285
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000050A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
INS51514Medicare UPIN