Provider Demographics
NPI:1326027590
Name:WOODBURY, BEVERLY LYNN (RN, CNP)
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:LYNN
Last Name:WOODBURY
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7720 164TH LN NW
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-3560
Mailing Address - Country:US
Mailing Address - Phone:763-753-4242
Mailing Address - Fax:
Practice Address - Street 1:401 CARLSON PARKWAY
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5387
Practice Address - Country:US
Practice Address - Phone:952-992-3637
Practice Address - Fax:952-992-3039
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD290710-23363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7632230900Medicaid
MN500002904Medicare ID - Type Unspecified
MN7632230900Medicaid