Provider Demographics
NPI:1811279789
Name:POWERS, BETH MARIE (NP)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:MARIE
Last Name:POWERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3860 S STRAITS HWY
Mailing Address - Street 2:
Mailing Address - City:INDIAN RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49749-5146
Mailing Address - Country:US
Mailing Address - Phone:231-238-0581
Mailing Address - Fax:231-238-0856
Practice Address - Street 1:3860 S STRAITS HWY
Practice Address - Street 2:
Practice Address - City:INDIAN RIVER
Practice Address - State:MI
Practice Address - Zip Code:49749-5146
Practice Address - Country:US
Practice Address - Phone:231-238-0581
Practice Address - Fax:231-238-0856
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704199609363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704199609OtherMICHIGAN LICENSE
OF96004OtherMEDICARE GROUP NUMBER