Provider Demographics
NPI:1336541259
Name:BEAUPRE, BROOKLYN (AG-ACNP)
Entity Type:Individual
Prefix:
First Name:BROOKLYN
Middle Name:
Last Name:BEAUPRE
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:408 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 24
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6089
Practice Address - Country:US
Practice Address - Phone:423-431-1810
Practice Address - Fax:423-431-1811
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19186363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100327340Medicaid
NC1336541259Medicaid
VA1336541259Medicaid
TNQ009458Medicaid
TN103I503316Medicare PIN