Provider Demographics
NPI:1235189861
Name:BEVERLY, LAURA NANCE (MD)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:NANCE
Last Name:BEVERLY
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:900 UNIVERSITY BLVD. NORTH
Mailing Address - Street 2:MC 75
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211
Mailing Address - Country:US
Mailing Address - Phone:904-253-2062
Mailing Address - Fax:904-253-1942
Practice Address - Street 1:1522 PENMAN RD.
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250
Practice Address - Country:US
Practice Address - Phone:904-253-2555
Practice Address - Fax:904-270-2559
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-01-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME59866208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3740781-01Medicaid
FL374078101Medicaid
FL3740781-01Medicaid