Provider Demographics
NPI:1073133468
Name:PREVILON, BETTIE MARIE
Entity Type:Individual
Prefix:
First Name:BETTIE
Middle Name:MARIE
Last Name:PREVILON
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 1:31 MAYNARD ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-4605
Mailing Address - Country:US
Mailing Address - Phone:781-475-6451
Mailing Address - Fax:
Practice Address - Street 1:31 MAYNARD ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-4605
Practice Address - Country:US
Practice Address - Phone:781-475-6451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-25
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN92701164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse