Healthcare Provider Details

I. General information

NPI: 1386627396
Provider Name (Legal Business Name): BETHANY STARR EDGE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDCOM ATTN: DCCS - QM (CREDENTIALS)
APO AP
96205-0054
KR

IV. Provider business mailing address

18TH MEDCOM ATTN: DCCS - QM (CREDENTIALS)
APO AP
96205-0054
KR

V. Phone/Fax

Practice location:
  • Phone: 01182279166027
  • Fax: 01182279178110
Mailing address:
  • Phone: 01182279166027
  • Fax: 01182279178110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: