1699040907 NPI number — BETHANY SHENE LPN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699040907 NPI number — BETHANY SHENE LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHENE
Provider First Name:
BETHANY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699040907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1994
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST HAMPTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11937-0908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-324-9555
Provider Business Mailing Address Fax Number:
631-458-1426

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 MCGRATH STAND LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAG HARBOR
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11963-2830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-741-8882
Provider Business Practice Location Address Fax Number:
631-458-1426
Provider Enumeration Date:
03/20/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , with the licence number:  212336 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 212336 . This is a "LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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