MEDICARE: MS. BETTY WILLIS

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	133V00000X	Registered Dietitian	ND3202	FL

General Provider Information

NPI Number	:	1992182786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BETTY WILLIS

Provider Business Mailing Address
First Line	:	400 HEALTH PARK BLVD
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32086-5784
Country	:	US
Telephone Number	:	904-819-4404
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 HEALTH PARK BLVD
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32086-5784
Country	:	US
Telephone Number	:	904-819-4404
Fax Number	:

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

Provider Enumeration Date	:	04/30/2015
Last Update Date	:	04/26/2026

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