Provider Demographics
NPI:1598795742
Name:NYSEWANDER, BEVERLY B (MSN ARNP)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:B
Last Name:NYSEWANDER
Suffix:
Gender:F
Credentials:MSN ARNP
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:B
Other - Last Name:NYSEWANDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSN ARNP
Mailing Address - Street 1:2080 CHILD STREET
Mailing Address - Street 2:NAVAL HOSPITAL JACKSONVILLE INTERNAL MEDICINE CLINIC
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214
Mailing Address - Country:US
Mailing Address - Phone:904-542-7310
Mailing Address - Fax:904-542-7913
Practice Address - Street 1:2080 CHILD STREET
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214
Practice Address - Country:US
Practice Address - Phone:904-542-7310
Practice Address - Fax:904-542-7913
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3342232363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3343652Medicare ID - Type Unspecified