1770573990 NPI number — MRS. SHAVONDA LATIEA BEAN MA, LPA

Table of content: MRS. SHAVONDA LATIEA BEAN MA, LPA (NPI 1770573990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770573990 NPI number — MRS. SHAVONDA LATIEA BEAN MA, LPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEAN
Provider First Name:
SHAVONDA
Provider Middle Name:
LATIEA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA, LPA
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:
1770573990
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8430 UNIVERSITY EXEC PARK DR
Provider Second Line Business Mailing Address:
SUITE 655
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28262-1350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-596-5553
Provider Business Mailing Address Fax Number:
704-596-1556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8430 UNIVERSITY EXEC PARK DR
Provider Second Line Business Practice Location Address:
SUITE 655
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28262-1350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-596-5553
Provider Business Practice Location Address Fax Number:
704-596-1556
Provider Enumeration Date:
10/27/2005

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: 103T00000X , with the licence number:  2477 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2118431 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: E4167-B0775 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 046KT . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6107067 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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