Provider Demographics
NPI:1730140484
Name:BEARD-ELY, VANESSA EILEEN (PA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:EILEEN
Last Name:BEARD-ELY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:96 E KIMBALLS LN
Practice Address - Street 2:STE 307
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5020
Practice Address - Country:US
Practice Address - Phone:801-260-3286
Practice Address - Fax:801-260-3285
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9060898-1206363A00000X
IN10000690A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ23073Medicare UPIN