Provider Demographics
NPI:1578957759
Name:BEALE, LATRICE
Entity Type:Individual
Prefix:
First Name:LATRICE
Middle Name:
Last Name:BEALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7025 HIGHWAY 25
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8288
Mailing Address - Country:US
Mailing Address - Phone:601-720-2865
Mailing Address - Fax:
Practice Address - Street 1:125 W NORTHSIDE DR # G
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-4723
Practice Address - Country:US
Practice Address - Phone:601-720-2865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01775546Medicaid