Provider Demographics
NPI:1821310962
Name:BETTS, IVY LYNN (RN)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:LYNN
Last Name:BETTS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 BARTLETT ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7005
Mailing Address - Country:US
Mailing Address - Phone:907-235-8101
Mailing Address - Fax:
Practice Address - Street 1:203 W PIONEER AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7527
Practice Address - Country:US
Practice Address - Phone:907-235-0369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK26187163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCMG799Medicaid
AKHH2711Medicaid
AKPCG519AMedicaid
AKHC2563Medicaid
AKMA0272Medicaid
AKNA3799Medicaid
AKMA0272Medicaid