Provider Demographics
NPI:1558488510
Name:BEAVER, ANGELA (OTR)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:
Last Name:BEAVER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MISS
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:LIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:5715 PORTWOOD PL
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-5143
Mailing Address - Country:US
Mailing Address - Phone:317-460-5146
Mailing Address - Fax:
Practice Address - Street 1:5300 W 96TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-3905
Practice Address - Country:US
Practice Address - Phone:317-873-8252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004126A286500000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No286500000XHospitalsMilitary Hospital