Provider Demographics
NPI:1801837836
Name:BECKHAM, TINA JEAN (FNP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:JEAN
Last Name:BECKHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11826 TRAPANI CT
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-3340
Mailing Address - Country:US
Mailing Address - Phone:805-529-0408
Mailing Address - Fax:
Practice Address - Street 1:1600 N ROSE AVE
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-3722
Practice Address - Country:US
Practice Address - Phone:805-988-2843
Practice Address - Fax:805-988-2844
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP14290 / RN515862363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ55532Medicare UPIN