Provider Demographics
NPI:1205677457
Name:BEASLEY, LAUREN ALENE (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ALENE
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 AUSTIN WAY
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-5064
Mailing Address - Country:US
Mailing Address - Phone:912-347-4471
Mailing Address - Fax:
Practice Address - Street 1:3193 E 1ST ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8830
Practice Address - Country:US
Practice Address - Phone:912-537-8588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12351207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine