Provider Demographics
NPI:1578850657
Name:BETANCOURT, TINA ANN
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:ANN
Last Name:BETANCOURT
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 1:3940 ARROWHEAD BLVD
Mailing Address - Street 2:
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302-7636
Mailing Address - Country:US
Mailing Address - Phone:919-568-7305
Mailing Address - Fax:919-568-7399
Practice Address - Street 1:3940 ARROWHEAD BLVD
Practice Address - Street 2:
Practice Address - City:MEBANE
Practice Address - State:NC
Practice Address - Zip Code:27302-7636
Practice Address - Country:US
Practice Address - Phone:919-568-7305
Practice Address - Fax:919-568-7399
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX711718163WP2201X
TXRN711718363LF0000X
NC280748163W00000X
NC5008228363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
No163W00000XNursing Service ProvidersRegistered Nurse