Provider Demographics
NPI:1740637370
Name:BETANCOURT RIVERA, WANDA SOCORRO (RN)
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:SOCORRO
Last Name:BETANCOURT RIVERA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:S
Other - Last Name:BETANCOURT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:2015 W WESTERN AVE
Mailing Address - Street 2:SUITE 132
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46619-3544
Mailing Address - Country:US
Mailing Address - Phone:574-229-8749
Mailing Address - Fax:574-855-1915
Practice Address - Street 1:2015 W WESTERN AVE STE 132
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46619-3561
Practice Address - Country:US
Practice Address - Phone:574-327-0140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28217649A163WH0200X, 163WI0500X, 163WW0000X, 372600000X, 374U00000X, 376J00000X, 376K00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide