Healthcare Provider Details

I. General information

NPI: 1184059594
Provider Name (Legal Business Name): BETHANY NICOLE MIDDLETON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 MARTIN ST
WINSTON SALEM NC
27103
US

IV. Provider business mailing address

601 N ELM ST
HIGH POINT NC
27262-4331
US

V. Phone/Fax

Practice location:
  • Phone: 336-448-9279
  • Fax:
Mailing address:
  • Phone: 336-878-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number9344
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberA9344
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: