1609673318 NPI number — BETHLYNN WAKEHOUSE SOLE PROPRIETOR

Table of content: BETHLYNN WAKEHOUSE SOLE PROPRIETOR (NPI 1609673318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609673318 NPI number — BETHLYNN WAKEHOUSE SOLE PROPRIETOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAKEHOUSE
Provider First Name:
BETHLYNN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SOLE PROPRIETOR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ANDERSON
Provider Other First Name:
BETHLYNN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
SOLE PROPRIETOR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609673318
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2106 TITAN SPRINGS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAPILLION
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68133-3420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-250-7296
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2106 TITAN SPRINGS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAPILLION
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68133-3420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-250-7296
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2025

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: 376J00000X , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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