Provider Demographics
NPI:1801236039
Name:HEANEY, BETH LAUREN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:LAUREN
Last Name:HEANEY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE BOX PSYCH
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-6070
Mailing Address - Fax:585-276-0067
Practice Address - Street 1:601 ELMWOOD AVE BOX PSYCH
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-6070
Practice Address - Fax:585-276-0067
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY402869363LP0808X
IL209012405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209012405OtherLICENSE NUMBER
IL370966854006Medicaid
IL370966854023Medicaid
IL370966854023Medicaid
640701Medicare Oscar/Certification