Provider Demographics
NPI:1508189242
Name:PLACK, BEVERLY SUE (RN)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:SUE
Last Name:PLACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 NW 153RD PL
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-5635
Mailing Address - Country:US
Mailing Address - Phone:503-690-8136
Mailing Address - Fax:
Practice Address - Street 1:2155 NW 153RD PL
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-5635
Practice Address - Country:US
Practice Address - Phone:503-690-8136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200841487RN163W00000X
WARN60096906163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse