Provider Demographics
NPI:1619503687
Name:BEAVER, SHERRI ROQUEL
Entity Type:Individual
Prefix:
First Name:SHERRI
Middle Name:ROQUEL
Last Name:BEAVER
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 1:3330 VAN HORN RD APT 146
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-4019
Mailing Address - Country:US
Mailing Address - Phone:734-747-3059
Mailing Address - Fax:
Practice Address - Street 1:3330 VAN HORN RD APT 146
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-4019
Practice Address - Country:US
Practice Address - Phone:734-747-3059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-20
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIB160765744775172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver