Provider Demographics
NPI:1982205829
Name:BEVERLY, BRITTANY NICOLE
Entity Type:Individual
Prefix:MISS
First Name:BRITTANY
Middle Name:NICOLE
Last Name:BEVERLY
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 1:236 N SUN ARBOR TER
Mailing Address - Street 2:APT 2111
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116
Mailing Address - Country:US
Mailing Address - Phone:385-777-9951
Mailing Address - Fax:
Practice Address - Street 1:236 N SUN ARBOR TER APT 2111
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-4537
Practice Address - Country:US
Practice Address - Phone:385-777-9951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT214819781390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT214819781Medicaid