MEDICARE: MS. PHYLLIS RUTH DALLA BETTA FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	47408	CO

General Provider Information

NPI Number	:	1548267479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PHYLLIS RUTH DALLA BETTA FNP

Provider Business Mailing Address
First Line	:	3103 ALMERIA WAY
Second Line	:
City	:	LONGMONT
State	:	CO
Zip	:	80503-7877
Country	:	US
Telephone Number	:	303-774-2068
Fax Number	:	303-774-2068

Provider Business Practice Location Address
First Line	:	4805 PRIME PKWY
Second Line	:
City	:	MCHENRY
State	:	IL
Zip	:	60050-7002
Country	:	US
Telephone Number	:	815-759-5448
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	04/09/2013

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