MEDICARE: BETHANY GILLMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	ARNP9287624	FL

General Provider Information

NPI Number	:	1356709588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETHANY GILLMAN

Provider Business Mailing Address
First Line	:	633 E BALDWIN RD
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4207
Country	:	US
Telephone Number	:	850-784-6696
Fax Number	:

Provider Business Practice Location Address
First Line	:	2195 JENKS AVE
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4682
Country	:	US
Telephone Number	:	850-784-6696
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2016
Last Update Date	:	06/29/2018

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