1548267479 NPI number — MS. PHYLLIS RUTH DALLA BETTA FNP

Table of content: MS. PHYLLIS RUTH DALLA BETTA FNP (NPI 1548267479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548267479 NPI number — MS. PHYLLIS RUTH DALLA BETTA FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DALLA BETTA
Provider First Name:
PHYLLIS
Provider Middle Name:
RUTH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1548267479
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3103 ALMERIA WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGMONT
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80503-7877
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-774-2068
Provider Business Mailing Address Fax Number:
303-774-2068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4805 PRIME PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCHENRY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60050-7002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-759-5448
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/07/2005

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:  47408 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com