Healthcare Provider Details

I. General information

NPI: 1376133496
Provider Name (Legal Business Name): KENATTA BETHEA PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 GRESHAM DR
NORFOLK VA
23507-1901
US

IV. Provider business mailing address

400 GRESHAM DR
NORFOLK VA
23507-1901
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-8866
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024180834
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: