Provider Demographics
NPI:1801664479
Name:PETREY, BETHANY
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:PETREY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5141 ROCKBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-9309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 GORDON GUTMANN BLVD STE 201
Practice Address - Street 2:
Practice Address - City:JEFFERSONVLLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3766
Practice Address - Country:US
Practice Address - Phone:812-282-6114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-13
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000449C367A00000X
KY4011242367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife