Provider Demographics
NPI:1942481486
Name:BEAUCHARD, ROSELENE PEGGY (LPN)
Entity Type:Individual
Prefix:
First Name:ROSELENE
Middle Name:PEGGY
Last Name:BEAUCHARD
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 1:5 PROSPECT PL
Mailing Address - Street 2:
Mailing Address - City:TOMKINS COVE
Mailing Address - State:NY
Mailing Address - Zip Code:10986-1213
Mailing Address - Country:US
Mailing Address - Phone:845-667-4894
Mailing Address - Fax:
Practice Address - Street 1:7 CAPT SHANKEY DR
Practice Address - Street 2:
Practice Address - City:GARNERVILLE
Practice Address - State:NY
Practice Address - Zip Code:10923-1326
Practice Address - Country:US
Practice Address - Phone:845-429-4347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190670-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01033623Medicaid