Provider Demographics
NPI:1043263064
Name:BEERY, GLORIA M (AS, BSN, FNP)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:M
Last Name:BEERY
Suffix:
Gender:F
Credentials:AS, BSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 E LEIGHFIELD DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5371
Mailing Address - Country:US
Mailing Address - Phone:208-855-2710
Mailing Address - Fax:208-855-0883
Practice Address - Street 1:1545 E LEIGHFIELD DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5371
Practice Address - Country:US
Practice Address - Phone:208-855-2710
Practice Address - Fax:208-855-0883
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP122A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNPGC7OtherBLUE CROSS
ID000010016742OtherBLUE SHIELD
ID1341167Medicare ID - Type Unspecified