Provider Demographics
NPI:1942587530
Name:BEAUVAIS, FADIALA MARIE
Entity Type:Individual
Prefix:
First Name:FADIALA
Middle Name:MARIE
Last Name:BEAUVAIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-2208
Mailing Address - Country:US
Mailing Address - Phone:978-452-1736
Mailing Address - Fax:
Practice Address - Street 1:148 WARREN ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2208
Practice Address - Country:US
Practice Address - Phone:978-452-1736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS53922660390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program