MEDICARE: MS. KATRINA K BENTLEY PHD, CNS, NP-C

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	NP-527A	ID

General Provider Information

NPI Number	:	1508843590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATRINA K BENTLEY PHD, CNS, NP-C

Provider Business Mailing Address
First Line	:	PO BOX 145
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-0145
Country	:	US
Telephone Number	:	208-983-5535
Fax Number	:	208-983-5575

Provider Business Practice Location Address
First Line	:	365 CENTER ROAD
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-1917
Country	:	US
Telephone Number	:	208-983-5535
Fax Number	:	208-983-5575

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

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	07/09/2007

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