Provider Demographics
NPI:1578235214
Name:BETRY, JOANNA IRENE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:IRENE
Last Name:BETRY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W4494 WILLOW BEND RD
Mailing Address - Street 2:
Mailing Address - City:WALDO
Mailing Address - State:WI
Mailing Address - Zip Code:53093-1758
Mailing Address - Country:US
Mailing Address - Phone:414-531-1463
Mailing Address - Fax:
Practice Address - Street 1:W4494 WILLOW BEND RD
Practice Address - Street 2:
Practice Address - City:WALDO
Practice Address - State:WI
Practice Address - Zip Code:53093-1758
Practice Address - Country:US
Practice Address - Phone:414-531-1463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11393363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily