Provider Demographics
NPI:1760684534
Name:BEASLEY, CARLA YVETTE (LPN)
Entity Type:Individual
Prefix:MS
First Name:CARLA
Middle Name:YVETTE
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 S GREEN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121
Mailing Address - Country:US
Mailing Address - Phone:216-382-0390
Mailing Address - Fax:
Practice Address - Street 1:14217 WESTROPP
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110
Practice Address - Country:US
Practice Address - Phone:216-486-0870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN109255164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2351217Medicaid