Provider Demographics
NPI:1801809991
Name:BEATY, JO ELAINE (CRNA)
Entity type:Individual
Prefix:
First Name:JO
Middle Name:ELAINE
Last Name:BEATY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6306 SHADOW WOOD DR
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-9626
Mailing Address - Country:US
Mailing Address - Phone:502-228-8576
Mailing Address - Fax:502-637-1550
Practice Address - Street 1:1400 POPLAR LEVEL RD STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1309
Practice Address - Country:US
Practice Address - Phone:502-637-4800
Practice Address - Fax:502-637-1550
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1039608367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74001405Medicaid
2441053OtherAETNA
KY1105370OtherPASSPORT
KY24364444000OtherPASSPORT ADVANTAGE
2441053OtherAETNA
KY1105370OtherPASSPORT