Healthcare Provider Details

I. General information

NPI: 1558843227
Provider Name (Legal Business Name): BETHANY LAUREN WADE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2018
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19TH ST 809
MIDDLESBORO KY
40965
US

IV. Provider business mailing address

271 REDBIRD CIR
CUMBERLAND GAP TN
37724-4178
US

V. Phone/Fax

Practice location:
  • Phone: 866-755-4258
  • Fax:
Mailing address:
  • Phone: 865-279-1989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: