Provider Demographics
NPI:1124173414
Name:NALLY, BETTY RICHARDS (NP)
Entity type:Individual
Prefix:MS
First Name:BETTY
Middle Name:RICHARDS
Last Name:NALLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 DAVINCI CT
Mailing Address - Street 2:SUITE 400
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-7627
Mailing Address - Country:US
Mailing Address - Phone:404-310-4582
Mailing Address - Fax:
Practice Address - Street 1:3720 DAVINCI CT
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-7627
Practice Address - Country:US
Practice Address - Phone:770-582-4189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN076930363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003146754AMedicaid
GA1124173414Medicare PIN