Provider Demographics
NPI:1023067766
Name:RICHARDSON, BETTY (CNFP)
Entity type:Individual
Prefix:MRS
First Name:BETTY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:CNFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 W CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2603
Mailing Address - Country:US
Mailing Address - Phone:601-833-9388
Mailing Address - Fax:601-833-9495
Practice Address - Street 1:421 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2709
Practice Address - Country:US
Practice Address - Phone:601-684-6891
Practice Address - Fax:601-249-3834
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR135080363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119592Medicaid
MSP06866Medicare UPIN
MS00119592Medicaid