Provider Demographics
NPI:1023628435
Name:BETANCOURT, SONIA ILDELISA (FNP-C)
Entity type:Individual
Prefix:
First Name:SONIA
Middle Name:ILDELISA
Last Name:BETANCOURT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 N STATE ST STE 3
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-6568
Mailing Address - Country:US
Mailing Address - Phone:951-652-6522
Mailing Address - Fax:
Practice Address - Street 1:621 N STATE ST
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-6567
Practice Address - Country:US
Practice Address - Phone:951-285-6115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-01
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95014929363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily