Provider Demographics
NPI:1417086422
Name:BEVERLY, KAREN LOUISE (STNA)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:LOUISE
Last Name:BEVERLY
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 S STATE ROUTE 19
Mailing Address - Street 2:APT. B
Mailing Address - City:OAK HARBOR
Mailing Address - State:OH
Mailing Address - Zip Code:43449-8700
Mailing Address - Country:US
Mailing Address - Phone:419-898-6740
Mailing Address - Fax:
Practice Address - Street 1:1070 S STATE ROUTE 19
Practice Address - Street 2:APT. B
Practice Address - City:OAK HARBOR
Practice Address - State:OH
Practice Address - Zip Code:43449-8700
Practice Address - Country:US
Practice Address - Phone:419-898-6740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH333291651199374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2509585Medicaid