Basic Information
| Provider Information | |||||||||
| NPI: | 1962840397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BETANCOURT | ||||||||
| FirstName: | SHELLY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MSN,MHA,WHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 639 E MAIN ST | ||||||||
| Address2: | PO BOX 670 | ||||||||
| City: | CARSON CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488119795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895843107 | ||||||||
| FaxNumber: | 9895846458 | ||||||||
| Practice Location | |||||||||
| Address1: | 639 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488119795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895843107 | ||||||||
| FaxNumber: | 9895846458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2013 | ||||||||
| LastUpdateDate: | 06/07/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LX0001X | 4704173045 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
No ID Information.