Provider Demographics
NPI:1043707771
Name:BETTS, LEEA NICOLE
Entity Type:Individual
Prefix:
First Name:LEEA
Middle Name:NICOLE
Last Name:BETTS
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 1:12 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-2314
Mailing Address - Country:US
Mailing Address - Phone:631-786-7608
Mailing Address - Fax:
Practice Address - Street 1:97 LITTLE NECK RD
Practice Address - Street 2:
Practice Address - City:CENTERPORT
Practice Address - State:NY
Practice Address - Zip Code:11721-1615
Practice Address - Country:US
Practice Address - Phone:631-629-5599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist