Provider Demographics
NPI:1841699139
Name:BEACH, BRENDA (APRN)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:BEACH
Suffix:
Gender:F
Credentials:APRN
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 931
Mailing Address - Street 2:
Mailing Address - City:WAR
Mailing Address - State:WV
Mailing Address - Zip Code:24892-0931
Mailing Address - Country:US
Mailing Address - Phone:304-888-4998
Mailing Address - Fax:304-875-3865
Practice Address - Street 1:14197 ROCKET BOYS DRIVE
Practice Address - Street 2:
Practice Address - City:WAR
Practice Address - State:WV
Practice Address - Zip Code:24892
Practice Address - Country:US
Practice Address - Phone:304-888-4998
Practice Address - Fax:304-875-3865
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV83247363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810027777Medicaid
WV511943Medicare Oscar/Certification
WV511901Medicare Oscar/Certification
WVWV4569AMedicare PIN
WVWV4569CMedicare PIN
WV511818Medicare Oscar/Certification
WV3810027777Medicaid
WV511819Medicare Oscar/Certification
WVWV4569BMedicare PIN