Provider Demographics
NPI:1659667954
Name:BEAUDRY, KATHERINE ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:ANN
Last Name:BEAUDRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 N KNOXVILLE AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5095
Mailing Address - Country:US
Mailing Address - Phone:309-691-2903
Mailing Address - Fax:
Practice Address - Street 1:5401 N KNOXVILLE AVE STE 115
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5095
Practice Address - Country:US
Practice Address - Phone:309-691-2903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-24
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036136919207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology