Provider Demographics
NPI:1588909519
Name:BETZ, KRISTIN RAE (NP)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:RAE
Last Name:BETZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:RAE
Other - Last Name:FIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN, FNP-BC
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:404 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948
Practice Address - Country:US
Practice Address - Phone:618-993-0056
Practice Address - Fax:618-993-0752
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009830363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881Medicare Oscar/Certification