Provider Demographics
NPI:1780808675
Name:LAURIE A BEACH
Entity type:Organization
Organization Name:LAURIE A BEACH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BEACH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:660-834-5100
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-0817
Mailing Address - Country:US
Mailing Address - Phone:573-335-4715
Mailing Address - Fax:573-334-2303
Practice Address - Street 1:212 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:PILOT GROVE
Practice Address - State:MO
Practice Address - Zip Code:65276-1005
Practice Address - Country:US
Practice Address - Phone:660-834-5100
Practice Address - Fax:660-834-5101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000014600OtherMEDICARE PART B