Healthcare Provider Details

I. General information

NPI: 1619390309
Provider Name (Legal Business Name): BETHANY BONDY WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2014
Last Update Date: 03/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 KINGSWAY CT STE A
TRENTON MI
48183-1959
US

IV. Provider business mailing address

1651 KINGSWAY CT STE A
TRENTON MI
48183-1959
US

V. Phone/Fax

Practice location:
  • Phone: 734-671-2110
  • Fax: 734-671-5344
Mailing address:
  • Phone: 734-671-2110
  • Fax: 734-671-5344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number4704175802
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: