1780810622 NPI number — MRS. LATANJA SHANTA BETTIS CRNP

Table of content: MRS. LATANJA SHANTA BETTIS CRNP (NPI 1780810622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780810622 NPI number — MRS. LATANJA SHANTA BETTIS CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BETTIS
Provider First Name:
LATANJA
Provider Middle Name:
SHANTA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNP
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:
1780810622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 E LAUREL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATMORE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36502-3014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-368-8001
Provider Business Mailing Address Fax Number:
251-368-8081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 E LAUREL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATMORE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36502-3014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-368-8001
Provider Business Practice Location Address Fax Number:
513-688-0812
Provider Enumeration Date:
06/05/2009

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:  1-088729 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 299404 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 630000013 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 011846 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1063439065 . This is a "NPI SITE GROUP PAYEE NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1093994758 . This is a "NPI SITE GROUP PAYEE NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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