Provider Demographics
NPI:1255752705
Name:BEAVERS, LINDA WILSON (AP)
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:WILSON
Last Name:BEAVERS
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MITCHELL DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6831
Mailing Address - Country:US
Mailing Address - Phone:813-404-6006
Mailing Address - Fax:
Practice Address - Street 1:345 E ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5253
Practice Address - Country:US
Practice Address - Phone:813-657-9590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3331171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist