Healthcare Provider Details

I. General information

NPI: 1750669537
Provider Name (Legal Business Name): BETTY TEMPLES MILL NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2011
Last Update Date: 07/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 WILLIAM B GRAHAM CT
KILMARNOCK VA
22482-3852
US

IV. Provider business mailing address

PO BOX 1694
KILMARNOCK VA
22482-1694
US

V. Phone/Fax

Practice location:
  • Phone: 804-435-0575
  • Fax: 804-435-9017
Mailing address:
  • Phone: 804-435-0575
  • Fax: 804-435-9017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0024110321
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number0024110321
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: