Provider Demographics
NPI:1710682422
Name:BETTENCOURT, SHAVON (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SHAVON
Middle Name:
Last Name:BETTENCOURT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:SHAVON
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:31 PARKVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-2919
Mailing Address - Country:US
Mailing Address - Phone:978-967-5077
Mailing Address - Fax:
Practice Address - Street 1:31 PARKVIEW AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2919
Practice Address - Country:US
Practice Address - Phone:978-967-5077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2300960163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse