Provider Demographics
NPI:1902120504
Name:NICKERSON, BETHANY ROSE
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:ROSE
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 N 200 E
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-2615
Mailing Address - Country:US
Mailing Address - Phone:435-687-4770
Mailing Address - Fax:
Practice Address - Street 1:54 N 200 E
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-2615
Practice Address - Country:US
Practice Address - Phone:435-687-4770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other