Provider Demographics
NPI:1265978720
Name:BEAZLEY, JOSEPHINE RITA (CNA)
Entity type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:RITA
Last Name:BEAZLEY
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10340 S KILDARE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-4804
Mailing Address - Country:US
Mailing Address - Phone:708-770-7700
Mailing Address - Fax:
Practice Address - Street 1:18656 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60340
Practice Address - Country:US
Practice Address - Phone:708-770-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid