Provider Demographics
NPI:1417327461
Name:BETTS, NICOLE (AGNP-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BETTS
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 FORTINO BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2076
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1310 FORTINO BLVD STE D
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008
Practice Address - Country:US
Practice Address - Phone:719-582-1898
Practice Address - Fax:719-621-4098
Is Sole Proprietor?:No
Enumeration Date:2015-10-02
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0992247-NP363LA2200X, 363LG0600X, 363LP2300X
CORN.0205125163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO69120251Medicaid