Provider Demographics
NPI:1902415243
Name:VAN VLECK, BETTINA JOY (RN)
Entity Type:Individual
Prefix:
First Name:BETTINA
Middle Name:JOY
Last Name:VAN VLECK
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:PO BOX 722
Mailing Address - Street 2:
Mailing Address - City:CENTER MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11934-0722
Mailing Address - Country:US
Mailing Address - Phone:631-495-1819
Mailing Address - Fax:
Practice Address - Street 1:725 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4314
Practice Address - Country:US
Practice Address - Phone:631-852-2680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY795175-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse