Provider Demographics
NPI:1992909238
Name:BETTENCOURT, GAIL W (CRNA)
Entity type:Individual
Prefix:MRS
First Name:GAIL
Middle Name:W
Last Name:BETTENCOURT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3998 FAIR RIDGE DR
Mailing Address - Street 2:SUITE # 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2129
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:
Practice Address - Street 1:326 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360
Practice Address - Country:US
Practice Address - Phone:860-889-8331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000400367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004199693Medicaid
CT430000112Medicare PIN