Healthcare Provider Details

I. General information

NPI: 1548267479
Provider Name (Legal Business Name): PHYLLIS RUTH DALLA BETTA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 PRIME PKWY
MCHENRY IL
60050-7002
US

IV. Provider business mailing address

3103 ALMERIA WAY
LONGMONT CO
80503-7877
US

V. Phone/Fax

Practice location:
  • Phone: 815-759-5448
  • Fax:
Mailing address:
  • Phone: 303-774-2068
  • Fax: 303-774-2068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number47408
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: