Healthcare Provider Details

I. General information

NPI: 1922596568
Provider Name (Legal Business Name): HANNAH J. BETTIS AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HANNAH J. ROTHE

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 10/18/2020
Certification Date: 10/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 N RUTLEDGE ST STE 1100
SPRINGFIELD IL
62702-4968
US

IV. Provider business mailing address

PO BOX 19628
SPRINGFIELD IL
62794-9628
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-4735
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-4735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209-017548
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209-017548
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: