Provider Demographics
NPI:1437661030
Name:BETTIS, SUSAN NICOLE (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:NICOLE
Last Name:BETTIS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 CHARLOTTE CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:AL
Mailing Address - Zip Code:36545-2203
Mailing Address - Country:US
Mailing Address - Phone:251-247-2596
Mailing Address - Fax:
Practice Address - Street 1:295 S JACKSON ST STE B
Practice Address - Street 2:
Practice Address - City:GROVE HILL
Practice Address - State:AL
Practice Address - Zip Code:36451-3231
Practice Address - Country:US
Practice Address - Phone:251-275-3173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-04
Last Update Date:2017-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-096756363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health