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General NPI Number Information
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NPI Number | 1922847235
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Entity Type | Individual
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Provider Name | BETHANY DUCKERT
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Gender | Female
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Dates
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Enumeration Date | 05/24/2024
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Last Update Date | 05/24/2024
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Provider Practice Location Address
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Address Line | 1350 CHARLES ST
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City | ROCKFORD
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State | IL
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Zip | 61104
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Country | US
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Telephone | 779-696-0600
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Fax |
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Provider Business Mailing Address
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Address Line | 4817 POPLAR CREEK DR
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City | MADISON
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State | WI
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Zip | 53718-2130
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Country | US
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Telephone | 920-960-0223
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 209.029730
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License Number State | IL
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