Provider Demographics
NPI:1235693268
Name:JUCKNATH, BEVERLY SUZANNE (APRN-C)
Entity Type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:SUZANNE
Last Name:JUCKNATH
Suffix:
Gender:F
Credentials:APRN-C
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Other - First Name:
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Mailing Address - Street 1:3003 W DR MLK BLVD FL JR2
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6307
Mailing Address - Country:US
Mailing Address - Phone:813-321-6580
Mailing Address - Fax:813-443-8185
Practice Address - Street 1:3003 W DR MARTIN LUTHER KING JR BLVD FL 2
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-321-6580
Practice Address - Fax:813-443-8185
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLRN9361508163WC0200X
FLAPRN11003292363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106459800Medicaid