Provider Demographics
NPI:1548267479
Name:DALLA BETTA, PHYLLIS RUTH (FNP)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:RUTH
Last Name:DALLA BETTA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 ALMERIA WAY
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-7877
Mailing Address - Country:US
Mailing Address - Phone:303-774-2068
Mailing Address - Fax:303-774-2068
Practice Address - Street 1:4805 PRIME PKWY
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-7002
Practice Address - Country:US
Practice Address - Phone:815-759-5448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO47408363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily