Provider Demographics
NPI:1447765789
Name:BEITO, MICHELE LYNN
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LYNN
Last Name:BEITO
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 1:17065 130TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-8524
Mailing Address - Country:US
Mailing Address - Phone:218-688-1221
Mailing Address - Fax:
Practice Address - Street 1:17065 130TH AVE NE
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-8524
Practice Address - Country:US
Practice Address - Phone:218-688-1221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN617930164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse