Basic Information
| Provider Information | |||||||||
| NPI: | 1134767627 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BETTIS | ||||||||
| FirstName: | PENNY | ||||||||
| MiddleName: | KAYE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APRN-CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2701 DURANGO DR | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720199602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5015516982 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720153353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017766000 | ||||||||
| FaxNumber: | 5017766208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2019 | ||||||||
| LastUpdateDate: | 12/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 121886 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.