Provider Demographics
NPI:1952625444
Name:BETANCOURT, ANNA MIRIAM (RD)
Entity Type:Individual
Prefix:MS
First Name:ANNA
Middle Name:MIRIAM
Last Name:BETANCOURT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 DAVIS PL S UNIT B
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-7988
Mailing Address - Country:US
Mailing Address - Phone:425-572-0327
Mailing Address - Fax:
Practice Address - Street 1:690 BARNES BOULEVARD
Practice Address - Street 2:MCCHORD AFB AIRMEN'S CLINIC
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98438-1304
Practice Address - Country:US
Practice Address - Phone:253-982-7973
Practice Address - Fax:253-982-0332
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANU00002007133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered