Provider Demographics
NPI:1205072840
Name:BEESON, MICHELLE ELAINE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELAINE
Last Name:BEESON
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 1:1301 CONCORD TER
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2843
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:954-858-1815
Practice Address - Street 1:3500 GASTON AVE
Practice Address - Street 2:BUSH ANNEX SUITE 112
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2017
Practice Address - Country:US
Practice Address - Phone:210-820-6318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-04
Last Update Date:2009-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX708816363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal