Provider Demographics
NPI:1013945849
Name:BEACH, DEBRA E (APN)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:E
Last Name:BEACH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10335 N PORT WASHINGTON RD
Mailing Address - Street 2:250
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5763
Mailing Address - Country:US
Mailing Address - Phone:262-240-9870
Mailing Address - Fax:242-260-9869
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001971363L00000X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILMB0920670OtherDEA