Provider Demographics
NPI:1871563361
Name:DAVIS, BETHANN H (NP)
Entity type:Individual
Prefix:
First Name:BETHANN
Middle Name:H
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:759 GRANITE ST
Mailing Address - Street 2:SOUTH SHORE HEALTH CENTER
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184
Mailing Address - Country:US
Mailing Address - Phone:781-848-1950
Mailing Address - Fax:781-356-4887
Practice Address - Street 1:759 GRANITE ST
Practice Address - Street 2:SOUTH SHORE HEALTH CENTER
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184
Practice Address - Country:US
Practice Address - Phone:781-848-1950
Practice Address - Fax:781-356-4887
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA194673363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP9770OtherBCBSMA
MANP2948Medicare ID - Type Unspecified
MAP21187Medicare UPIN