Basic Information
| Provider Information | |||||||||
| NPI: | 1740426493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BETZ | ||||||||
| FirstName: | BERTHA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 308 RIDGEHILL DR | ||||||||
| Address2: | |||||||||
| City: | HOPKINSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422404918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703483030 | ||||||||
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| Practice Location | |||||||||
| Address1: | 650 JOEL DR | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2008 | ||||||||
| LastUpdateDate: | 12/31/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 2019340 | KY | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.