Provider Demographics
NPI:1578245239
Name:BETTIS, NICOLE R
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:BETTIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 SE OLD OLYMPIC HWY
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-7726
Mailing Address - Country:US
Mailing Address - Phone:360-789-5281
Mailing Address - Fax:
Practice Address - Street 1:2390 SE OLD OLYMPIC HWY
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-7726
Practice Address - Country:US
Practice Address - Phone:360-789-5281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60239149163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse