Provider Demographics
NPI:1437660701
Name:BEVERLY, PHILLENTHIA
Entity Type:Individual
Prefix:MRS
First Name:PHILLENTHIA
Middle Name:
Last Name:BEVERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9001 TRAIL CREEK CT
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-8068
Mailing Address - Country:US
Mailing Address - Phone:501-833-0206
Mailing Address - Fax:501-833-0206
Practice Address - Street 1:9001 TRAIL CREEK CT
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-8068
Practice Address - Country:US
Practice Address - Phone:501-833-0206
Practice Address - Fax:501-833-0206
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR81-5363605Medicaid