Provider Demographics
NPI:1164177747
Name:BEATTIE, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BEATTIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 ALLEN AVE APT A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-3971
Mailing Address - Country:US
Mailing Address - Phone:734-972-1707
Mailing Address - Fax:
Practice Address - Street 1:1007 ALLEN AVE APT A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-3971
Practice Address - Country:US
Practice Address - Phone:734-972-1707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-13
Last Update Date:2022-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019008307133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered