1174060495 NPI number — MRS. STEPHANIE MARIE BETSWORTH APRN-C

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 1174060495 NPI number — MRS. STEPHANIE MARIE BETSWORTH APRN-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BETSWORTH
Provider First Name:
STEPHANIE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TALLEY
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174060495
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15710 W 135TH ST STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLATHE
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66062-1508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-297-7472
Provider Business Mailing Address Fax Number:
913-764-0336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15710 W 135TH ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
OLATHE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66062-1511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-297-7472
Provider Business Practice Location Address Fax Number:
913-764-0336
Provider Enumeration Date:
01/24/2017

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: 363LF0000X , with the licence number:  2022005296 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 77536 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 033D00183 . This is a "WPS MEDICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 201177750A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".