Provider Demographics
NPI:1558494724
Name:BETTS, DAVINA MONIQUE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DAVINA
Middle Name:MONIQUE
Last Name:BETTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DAVINA
Other - Middle Name:MONIQUE
Other - Last Name:KEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 RIVERSIDE DR STE 2800
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-5004
Mailing Address - Country:US
Mailing Address - Phone:815-935-1100
Mailing Address - Fax:815-937-5966
Practice Address - Street 1:400 RIVERSIDE DR STE 2800
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-5004
Practice Address - Country:US
Practice Address - Phone:815-935-1100
Practice Address - Fax:815-937-5966
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001933363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant