Provider Demographics
NPI:1912371105
Name:RICHARDSON, BEVERLY (LPN)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:
Other - Last Name:LAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:43825 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2551
Mailing Address - Country:US
Mailing Address - Phone:734-397-9088
Mailing Address - Fax:
Practice Address - Street 1:43825 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-2551
Practice Address - Country:US
Practice Address - Phone:734-397-9088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-25
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703064168164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse