Provider Demographics
NPI:1912772161
Name:BEAM, CARLA RENEE
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:RENEE
Last Name:BEAM
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 1:7500 S COUNTRY CLUB DR APT 202C
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-5157
Mailing Address - Country:US
Mailing Address - Phone:405-589-5662
Mailing Address - Fax:
Practice Address - Street 1:2901 SE 22ND ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73129-8413
Practice Address - Country:US
Practice Address - Phone:405-677-0502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-17
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK400043700822376K00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No376K00000XNursing Service Related ProvidersNurse's Aide