Provider Demographics
NPI:1275053514
Name:BEAUCHAMP, ANGELA DENISE (PA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:DENISE
Last Name:BEAUCHAMP
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:DENISE
Other - Last Name:VAIL, FREEBORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:509-227-7070
Practice Address - Street 1:1402 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-5001
Practice Address - Country:US
Practice Address - Phone:509-455-8220
Practice Address - Fax:509-455-9172
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60769549208000000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty