Healthcare Provider Details

I. General information

NPI: 1508843590
Provider Name (Legal Business Name): KATRINA K BENTLEY PHD, CNS, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 CENTER ROAD
GRANGEVILLE ID
83530-1917
US

IV. Provider business mailing address

PO BOX 145
GRANGEVILLE ID
83530-0145
US

V. Phone/Fax

Practice location:
  • Phone: 208-983-5535
  • Fax: 208-983-5575
Mailing address:
  • Phone: 208-983-5535
  • Fax: 208-983-5575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP-527A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: