1174514632 NPI number — MRS. BETTY CHAPMAN PETREE CRNA

Table of content: MRS. BETTY CHAPMAN PETREE CRNA (NPI 1174514632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174514632 NPI number — MRS. BETTY CHAPMAN PETREE CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETREE
Provider First Name:
BETTY
Provider Middle Name:
CHAPMAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1174514632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
MEDICAL CENTER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27157-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-713-2540
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER
Provider Second Line Business Practice Location Address:
MEDICAL CENTER BLVD
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27157-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-713-2540
Provider Business Practice Location Address Fax Number:
336-713-2539
Provider Enumeration Date:
11/03/2005

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: 367500000X , with the licence number:  045160 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8050232 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 260473D . This is a "PSC MEDICARE PROVIDER #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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