Provider Demographics
NPI:1851929947
Name:BETZ, MARY EMMA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:EMMA
Last Name:BETZ
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 1:3415 SE POWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3396
Mailing Address - Country:US
Mailing Address - Phone:503-234-9591
Mailing Address - Fax:
Practice Address - Street 1:3415 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3396
Practice Address - Country:US
Practice Address - Phone:503-234-9591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202001137RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse