Provider Demographics
NPI:1205459310
Name:DAVIS, BETHANY (PMHNP)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:394 TRAILING PUTT WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5003
Mailing Address - Country:US
Mailing Address - Phone:909-418-1803
Mailing Address - Fax:
Practice Address - Street 1:911 N BUFFALO DR UNIT 206
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0381
Practice Address - Country:US
Practice Address - Phone:909-418-1803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-22
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRN99181163W00000X
NV831439363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse