Provider Demographics
NPI:1134778954
Name:PUTT, BETTY
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:PUTT
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 1:5146 AIRLINE RD
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-5527
Mailing Address - Country:US
Mailing Address - Phone:903-431-7801
Mailing Address - Fax:
Practice Address - Street 1:5146 AIRLINE RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5527
Practice Address - Country:US
Practice Address - Phone:903-431-7801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider