Healthcare Provider Details

I. General information

NPI: 1104691658
Provider Name (Legal Business Name): BETHANY L MADDEN ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETHANY L STARK

II. Dates (important events)

Enumeration Date: 11/15/2023
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 1ST AVE SW
CASTLE ROCK WA
98611
US

IV. Provider business mailing address

1057 12TH AVE
LONGVIEW WA
98632-2509
US

V. Phone/Fax

Practice location:
  • Phone: 360-814-2353
  • Fax: 360-274-7439
Mailing address:
  • Phone: 360-636-3892
  • Fax: 360-414-1342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61478800
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: