Provider Demographics
NPI:1407287709
Name:MAYBERRY, BETH
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:A
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:520 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:MILLSTADT
Mailing Address - State:IL
Mailing Address - Zip Code:62260-1428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 W MADISON ST
Practice Address - Street 2:
Practice Address - City:MILLSTADT
Practice Address - State:IL
Practice Address - Zip Code:62260-1428
Practice Address - Country:US
Practice Address - Phone:618-980-3819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010013255163W00000X
SC206901163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse