Provider Demographics
NPI:1154310324
Name:WICKS, BEVERLY (ARNO)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:WICKS
Suffix:
Gender:F
Credentials:ARNO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2987 PEBBLE CREEK ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-7161
Mailing Address - Country:US
Mailing Address - Phone:321-279-8320
Mailing Address - Fax:
Practice Address - Street 1:111 GRANADA CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-3802
Practice Address - Country:US
Practice Address - Phone:407-420-1771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP421302363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE3026BMedicaid
FLS88478Medicare ID - Type UnspecifiedARNP
FLE3026BMedicaid