Provider Demographics
NPI:1609382209
Name:BEVERLY ADVANCED PRACTICE NURSING, PLLC
Entity Type:Organization
Organization Name:BEVERLY ADVANCED PRACTICE NURSING, PLLC
Other - Org Name:THE BEVERLY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:DAYTRAL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:903-212-7788
Mailing Address - Street 1:PO BOX 883
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-0883
Mailing Address - Country:US
Mailing Address - Phone:903-212-7788
Mailing Address - Fax:
Practice Address - Street 1:103A WOODBINE PL
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-2912
Practice Address - Country:US
Practice Address - Phone:903-212-7788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP120067261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care