Healthcare Provider Details

I. General information

NPI: 1205253580
Provider Name (Legal Business Name): BETHANIE LYNN NICE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 GREENBRIER PKWY STE 100
CHESAPEAKE VA
23320
US

IV. Provider business mailing address

824 GREENBRIER PKWY STE 100
CHESAPEAKE VA
23320-3697
US

V. Phone/Fax

Practice location:
  • Phone: 217-821-7013
  • Fax:
Mailing address:
  • Phone: 217-821-7013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number0024175005
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: