Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 23615 | SC |
N | 363LG0600X | Nurse Practitioner - Gerontology | 23614 | SC |
N | 363LG0600X | Nurse Practitioner - Gerontology | 5012875 | NC |
NPI | 1013552587 |
---|---|
Provider Name | Latoni Timesha Bethea |
First Address | West Columbia, SC 29169 |
Second Address | West Columbia, SC 29169 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2019 |
Last Update Date | 24/03/2020 |