Provider Demographics
NPI:1104383173
Name:STATES, BEAU (RN)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:
Last Name:STATES
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 CEDAR RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NEW PALTZ
Mailing Address - State:NY
Mailing Address - Zip Code:12561-2711
Mailing Address - Country:US
Mailing Address - Phone:818-645-1425
Mailing Address - Fax:
Practice Address - Street 1:560 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3917
Practice Address - Country:US
Practice Address - Phone:818-645-1425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY703282163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse