Provider Demographics
NPI:1508377557
Name:BEVERIDGE, MIA (NP)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:BEVERIDGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-5069
Mailing Address - Country:US
Mailing Address - Phone:334-319-3641
Mailing Address - Fax:
Practice Address - Street 1:3316 HIGHWAY 280
Practice Address - Street 2:
Practice Address - City:ALEXANDER CITY
Practice Address - State:AL
Practice Address - Zip Code:35010-3369
Practice Address - Country:US
Practice Address - Phone:256-329-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN221664363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily