Provider Demographics
NPI:1720350770
Name:BETHEL, CLARISSE (RN, BSN)
Entity Type:Individual
Prefix:
First Name:CLARISSE
Middle Name:
Last Name:BETHEL
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:CLARISSE
Other - Middle Name:
Other - Last Name:KAMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:1408 GOLF COURSE DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-2330
Mailing Address - Country:US
Mailing Address - Phone:240-643-5523
Mailing Address - Fax:301-808-3060
Practice Address - Street 1:1408 GOLF COURSE DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20721-2330
Practice Address - Country:US
Practice Address - Phone:240-643-5523
Practice Address - Fax:301-808-3060
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR176704163W00000X
MDLP42451164W00000X
251E00000X
MD31841374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No251E00000XAgenciesHome Health
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDNPI 53790037Medicaid