Provider Demographics
NPI:1962043562
Name:BEAUDOIN, CELYNNE JOELLE
Entity Type:Individual
Prefix:
First Name:CELYNNE
Middle Name:JOELLE
Last Name:BEAUDOIN
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 1:7224 S ELWOOD AVE APT 29208
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74132-2462
Mailing Address - Country:US
Mailing Address - Phone:405-315-3087
Mailing Address - Fax:
Practice Address - Street 1:1135 N BISHOP AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-4114
Practice Address - Country:US
Practice Address - Phone:214-942-3100
Practice Address - Fax:214-948-3697
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA15300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program