Provider Demographics
NPI:1497315121
Name:BEAUVAIS, WILDA B
Entity Type:Individual
Prefix:DR
First Name:WILDA
Middle Name:B
Last Name:BEAUVAIS
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 1:6453 PEMBROKE RD FL 33025
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33023-2137
Mailing Address - Country:US
Mailing Address - Phone:954-559-4066
Mailing Address - Fax:
Practice Address - Street 1:6453 PEMBROKE RD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33023-2137
Practice Address - Country:US
Practice Address - Phone:954-559-4066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL376G00000X
FLRN9435744163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL83-1548904Medicaid