Provider Demographics
NPI:1760578538
Name:BEACOM, LUANN SUE (NP)
Entity Type:Individual
Prefix:MS
First Name:LUANN
Middle Name:SUE
Last Name:BEACOM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5383 BOTHE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122
Mailing Address - Country:US
Mailing Address - Phone:858-546-9088
Mailing Address - Fax:
Practice Address - Street 1:4060 4TH AVE
Practice Address - Street 2:SUITE 420
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:619-299-3111
Practice Address - Fax:619-299-3126
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9876363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA249OtherCLIN. NURSE SPEC CERT #
CA9876OtherN.P. FURNISHING #
CARN336125OtherR.N. LICENSE #
CARN336125OtherR.N. LICENSE #
CAMB0596760OtherDEA NUMBER
CARN336125OtherR.N. LICENSE #
CA9876OtherN.P. FURNISHING #