Provider Demographics
NPI:1679355150
Name:WASHINGTON, BERETHA JO
Entity type:Individual
Prefix:
First Name:BERETHA
Middle Name:JO
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MARKAVIEW RD NW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35805-3652
Mailing Address - Country:US
Mailing Address - Phone:205-899-5712
Mailing Address - Fax:
Practice Address - Street 1:500 MARKAVIEW RD NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35805-3652
Practice Address - Country:US
Practice Address - Phone:205-933-8101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-103270163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse