Provider Demographics
NPI:1043837768
Name:BETARD-BOYD, NICHELLE (LPN)
Entity type:Individual
Prefix:
First Name:NICHELLE
Middle Name:
Last Name:BETARD-BOYD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:NICHELLE
Other - Middle Name:
Other - Last Name:BETARD-BOYD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:1534 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-2830
Mailing Address - Country:US
Mailing Address - Phone:631-633-4520
Mailing Address - Fax:
Practice Address - Street 1:23 BRITTANY CT
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3225
Practice Address - Country:US
Practice Address - Phone:631-633-4520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338519164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse