Basic Information
| Provider Information | |||||||||
| NPI: | 1568779239 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BETTINGER | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | SUE | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 S WATER ST | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442403548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663892727 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 S WATER ST | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442403548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663892727 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2010 | ||||||||
| LastUpdateDate: | 02/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F0810119 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | APRN.CNP.11889 | 05 | OH | MEDICAID |