Healthcare Provider Details

I. General information

NPI: 1750285128
Provider Name (Legal Business Name): NICOLE RUTH BETTIS IX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2467 MORA LOOP APT B
HOLLOMAN AFB NM
88330-8557
US

IV. Provider business mailing address

2467 MORA LOOP APT B
HOLLOMAN AFB NM
88330-8557
US

V. Phone/Fax

Practice location:
  • Phone: 609-966-0303
  • Fax:
Mailing address:
  • Phone: 609-966-0303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number106E00000X
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: