Basic Information
| Provider Information | |||||||||
| NPI: | 1013404292 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BETHEL-WILSON | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 580 MAGNOLIA DR | ||||||||
| Address2: | |||||||||
| City: | DOUGLASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301346634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043957401 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4055 VALLEY VIEW LN | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752445074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727153800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2018 | ||||||||
| LastUpdateDate: | 04/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | RN181956 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 308544 | NY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.