Provider Demographics
NPI:1396226981
Name:BETTY, NICOLE (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:BETTY
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 NW MIAMI GARDENS DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-4467
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:413 W WATER STREET
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:MO
Practice Address - Zip Code:65661
Practice Address - Country:US
Practice Address - Phone:636-675-5665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017042680207N00000X, 207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine