1407391212 NPI number — MS. DAVENA JANEEN BEAL PMH-NP

Table of content: MS. DAVENA JANEEN BEAL PMH-NP (NPI 1407391212)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407391212 NPI number — MS. DAVENA JANEEN BEAL PMH-NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEAL
Provider First Name:
DAVENA
Provider Middle Name:
JANEEN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PMH-NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407391212
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5747 W WARWICK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60634-2658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-332-7145
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2340 S HIGHLAND AVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
LOMBARD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60148-5371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-261-1210
Provider Business Practice Location Address Fax Number:
630-261-1211
Provider Enumeration Date:
01/03/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  209.015353 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)