Provider Demographics
NPI:1386897569
Name:FETTERS, BECKY JANELL
Entity type:Individual
Prefix:MRS
First Name:BECKY
Middle Name:JANELL
Last Name:FETTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-4419
Mailing Address - Country:US
Mailing Address - Phone:307-742-6840
Mailing Address - Fax:
Practice Address - Street 1:807 S 3RD ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-4419
Practice Address - Country:US
Practice Address - Phone:307-742-6840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist