Provider Demographics
NPI:1245952258
Name:BEAVER, KELLY ANN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:BEAVER
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 1:2410 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:POINT PLEASANT
Mailing Address - State:WV
Mailing Address - Zip Code:25550-1528
Mailing Address - Country:US
Mailing Address - Phone:304-675-7400
Mailing Address - Fax:
Practice Address - Street 1:2401 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:POINT PLEASANT
Practice Address - State:WV
Practice Address - Zip Code:25550-1527
Practice Address - Country:US
Practice Address - Phone:304-675-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24958163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health