Provider Demographics
NPI:1811993264
Name:BEACH, LAURIE ANN
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:ANN
Last Name:BEACH
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:PO BOX 271430
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80527-1430
Mailing Address - Country:US
Mailing Address - Phone:970-488-1640
Mailing Address - Fax:970-472-9381
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:660-831-3728
Practice Address - Fax:660-831-3326
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110297363LF0000X, 363LF0000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000082595OtherMEDICARE NUMBER
MO001014600OtherMEDICARE PART B
MO000082595OtherMEDICARE NUMBER
MOS73161Medicare UPIN