1942041660 NPI number — MRS. KELLY LOUISE BEAVERS APRN, FNP-C

Table of content: MRS. KELLY LOUISE BEAVERS APRN, FNP-C (NPI 1942041660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942041660 NPI number — MRS. KELLY LOUISE BEAVERS APRN, FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEAVERS
Provider First Name:
KELLY
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN, FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942041660
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 8500 LOCK BOX 7642
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19178-7642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-821-8478
Provider Business Mailing Address Fax Number:
813-281-8113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 SAMFORD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71103-4239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-226-3306
Provider Business Practice Location Address Fax Number:
318-226-3319
Provider Enumeration Date:
06/05/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  235754 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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