Provider Demographics
NPI:1104658608
Name:CARRASQUILLO, BETSY S
Entity type:Individual
Prefix:
First Name:BETSY
Middle Name:S
Last Name:CARRASQUILLO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 LAKE HOLLINGSWORTH DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-5607
Mailing Address - Country:US
Mailing Address - Phone:863-680-4111
Mailing Address - Fax:
Practice Address - Street 1:5381 PRIMROSE LAKE CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3521
Practice Address - Country:US
Practice Address - Phone:813-615-2488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-14
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11034568363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily