Provider Demographics
NPI:1750349791
Name:TEAGLE, BEVERLY ELAINE (CNP)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:ELAINE
Last Name:TEAGLE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PASEO DEL PUEBLO SUR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6070
Mailing Address - Country:US
Mailing Address - Phone:575-758-3005
Mailing Address - Fax:575-758-7010
Practice Address - Street 1:630 PASEO DEL PUEBLO SUR
Practice Address - Street 2:SUITE 150
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6070
Practice Address - Country:US
Practice Address - Phone:575-758-3005
Practice Address - Fax:575-758-7010
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2014-09-22
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-03
Provider Licenses
StateLicense IDTaxonomies
NMR33815163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM$$$$$$$$$Medicare PIN
S87264Medicare UPIN