Provider Demographics
NPI:1568466480
Name:CASSIDY, BEAU (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:BEAU
Middle Name:
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 ANTHONY CT
Mailing Address - Street 2:
Mailing Address - City:CASTALIAN SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37031-4549
Mailing Address - Country:US
Mailing Address - Phone:423-967-6224
Mailing Address - Fax:
Practice Address - Street 1:602 RED BOILING SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:TN
Practice Address - Zip Code:37083-1316
Practice Address - Country:US
Practice Address - Phone:615-237-5410
Practice Address - Fax:615-237-5411
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8375363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ000435Medicaid
VA1568466480Medicaid
VA1568466480Medicaid
TN103I504209Medicare PIN
VAVV9505BMedicare PIN
P43487Medicare UPIN
TN3908741Medicare ID - Type Unspecified
TNP00071746Medicare PIN
0281780001Medicare PIN
0281780003Medicare PIN