Provider Demographics
NPI:1235393752
Name:BEASLEY, SOMPHONE S (MSN, FNP)
Entity Type:Individual
Prefix:MRS
First Name:SOMPHONE
Middle Name:S
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2555 NE BELVUE ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4202
Practice Address - Country:US
Practice Address - Phone:541-768-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200850063NP FNP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500601707Medicaid
ORR144855Medicare PIN