Provider Demographics
NPI:1962840397
Name:BETANCOURT, SHELLY L (MSN,MHA,WHNP-BC)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:L
Last Name:BETANCOURT
Suffix:
Gender:F
Credentials:MSN,MHA,WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 E MAIN ST
Mailing Address - Street 2:PO BOX 670
Mailing Address - City:CARSON CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48811-9795
Mailing Address - Country:US
Mailing Address - Phone:989-584-3107
Mailing Address - Fax:989-584-6458
Practice Address - Street 1:639 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:MI
Practice Address - Zip Code:48811-9795
Practice Address - Country:US
Practice Address - Phone:989-584-3107
Practice Address - Fax:989-584-6458
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704173045363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology