Provider Demographics
NPI:1164295929
Name:MCGRUDER, BETTINA NORWOOD
Entity Type:Individual
Prefix:
First Name:BETTINA
Middle Name:NORWOOD
Last Name:MCGRUDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETTINA
Other - Middle Name:
Other - Last Name:HARPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 HASTINGS AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-7013
Mailing Address - Country:US
Mailing Address - Phone:573-842-8891
Mailing Address - Fax:
Practice Address - Street 1:110 HASTINGS AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-7013
Practice Address - Country:US
Practice Address - Phone:573-842-8891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS884706163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice