Provider Demographics
NPI:1770979650
Name:PERRY, BETHANY N (APNP)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:N
Last Name:PERRY
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3116
Mailing Address - Country:US
Mailing Address - Phone:920-877-3102
Mailing Address - Fax:920-855-8790
Practice Address - Street 1:130 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3116
Practice Address - Country:US
Practice Address - Phone:920-877-3102
Practice Address - Fax:920-855-8790
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6268-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1770979650Medicaid
WIK400207466Medicare PIN