Provider Demographics
NPI:1124534219
Name:BEAUCHAMP, GLENN STEPHEN
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:STEPHEN
Last Name:BEAUCHAMP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 MILL RD APT 3A
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-4747
Mailing Address - Country:US
Mailing Address - Phone:718-979-6900
Mailing Address - Fax:718-979-6940
Practice Address - Street 1:245 MILL RD APT 3A
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-4747
Practice Address - Country:US
Practice Address - Phone:718-979-6900
Practice Address - Fax:718-979-6940
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-27
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY604168-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse