Provider Demographics
NPI:1508633173
Name:BEVELY, ESTELISA (RN)
Entity Type:Individual
Prefix:
First Name:ESTELISA
Middle Name:
Last Name:BEVELY
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 1:1501 DORIS AVE
Mailing Address - Street 2:
Mailing Address - City:CAHOKIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62206-2235
Mailing Address - Country:US
Mailing Address - Phone:618-741-9714
Mailing Address - Fax:
Practice Address - Street 1:505 S 8TH ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62201-2919
Practice Address - Country:US
Practice Address - Phone:618-482-7330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041178213163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)