Provider Demographics
NPI:1851308589
Name:QUENNEVILLE, BEVERLY TIPPENS (PA-C)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:TIPPENS
Last Name:QUENNEVILLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:F
Other - Last Name:TIPPENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:530 FONTAINE ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503
Practice Address - Country:US
Practice Address - Phone:800-243-7546
Practice Address - Fax:850-484-8223
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103191363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292339400Medicaid
FLY0K2NOtherBLUE CROSS BLUE SHIELD
AL591-89444OtherBLUE CROSS BLUE SHIELD
AL592-27571OtherBLUE CROSS BLUE SHIELD
FL292339400Medicaid
FLHS527ZMedicare PIN