Provider Demographics
NPI:1740673789
Name:WELCH, BEVERLY
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:WELCH
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 1:3304 KINGSLAND AVE
Mailing Address - Street 2:2
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-2712
Mailing Address - Country:US
Mailing Address - Phone:718-490-2841
Mailing Address - Fax:
Practice Address - Street 1:3304 KINGSLAND AVE
Practice Address - Street 2:2
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-2712
Practice Address - Country:US
Practice Address - Phone:718-490-2841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY566064163W00000X, 313M00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY163W00000XMedicaid