Provider Demographics
NPI:1720404205
Name:BEAVERS, ANGEL SHELTON
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:SHELTON
Last Name:BEAVERS
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 1:6255 BETHANY ROAD
Mailing Address - Street 2:
Mailing Address - City:RUSTBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24588
Mailing Address - Country:US
Mailing Address - Phone:434-258-4426
Mailing Address - Fax:
Practice Address - Street 1:1613 OAKWOOD ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-1213
Practice Address - Country:US
Practice Address - Phone:800-554-5517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-08
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001178518163W00000X
VA0024171546363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse