Provider Demographics
NPI:1952486243
Name:NICKERSON, BEVERLY B (NP)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:B
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E 28TH ST STE 318
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2785
Mailing Address - Country:US
Mailing Address - Phone:562-290-8888
Mailing Address - Fax:
Practice Address - Street 1:701 E 28TH ST STE 318
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2785
Practice Address - Country:US
Practice Address - Phone:562-290-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP # 12061174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12061OtherNURSE PRACTITIONER
CA300404OtherREGISTERED NURSE