Provider Demographics
NPI:1144827957
Name:PETERSON, BETHANY AMANDA (NP-C)
Entity type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:AMANDA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776
Mailing Address - Street 2:
Mailing Address - City:CATAULA
Mailing Address - State:GA
Mailing Address - Zip Code:31804-0776
Mailing Address - Country:US
Mailing Address - Phone:706-570-3965
Mailing Address - Fax:
Practice Address - Street 1:6228 BRADLEY PARK DR STE A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-3605
Practice Address - Country:US
Practice Address - Phone:706-322-1486
Practice Address - Fax:706-324-3419
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN213705363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily