Provider Demographics
NPI:1477297190
Name:BEAN, KERIEA TIA
Entity Type:Individual
Prefix:
First Name:KERIEA
Middle Name:TIA
Last Name:BEAN
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 1:900 VILLAGE SQUARE XING STE 290
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2395 S WASHINGTON AVE STE 1
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-4702
Practice Address - Country:US
Practice Address - Phone:321-385-7979
Practice Address - Fax:321-385-7978
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11019420207N00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207N00000XAllopathic & Osteopathic PhysiciansDermatology