Healthcare Provider Details

I. General information

NPI: 1538964812
Provider Name (Legal Business Name): BETHENY GASTON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2025
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6830 ANDERSON ST
SHAWNEE KS
66226-3101
US

IV. Provider business mailing address

4809 SHADY BEND RD
LEAVENWORTH KS
66048-2243
US

V. Phone/Fax

Practice location:
  • Phone: 816-922-2750
  • Fax:
Mailing address:
  • Phone: 580-917-2939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number4216315
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number684902
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: