Provider Demographics
NPI:1093016032
Name:GAYLES, BEVERLY ANN (LPN)
Entity Type:Individual
Prefix:MISS
First Name:BEVERLY
Middle Name:ANN
Last Name:GAYLES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11404 WARREN BLVD APT 102
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-1044
Mailing Address - Country:US
Mailing Address - Phone:313-740-1390
Mailing Address - Fax:
Practice Address - Street 1:13929 HARPER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3672
Practice Address - Country:US
Practice Address - Phone:313-371-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703083426164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse