Provider Demographics
NPI:1598267874
Name:BEVERLY, ILLIANA ANNETTE
Entity Type:Individual
Prefix:
First Name:ILLIANA
Middle Name:ANNETTE
Last Name:BEVERLY
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 1:497 WALMAR RD
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-1521
Mailing Address - Country:US
Mailing Address - Phone:803-318-4324
Mailing Address - Fax:
Practice Address - Street 1:1801 SUPERIOR AVE E
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-2135
Practice Address - Country:US
Practice Address - Phone:216-509-3480
Practice Address - Fax:866-608-0504
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator