1770987398 NPI number — MICHELE BEAUTON

Table of content: BARBARA ANNMARIE NICHOLS-WARREN LPN (NPI 1730582099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770987398 NPI number — MICHELE BEAUTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEAUTON
Provider First Name:
MICHELE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1770987398
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 963
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT DORA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32756-0963
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-668-6222
Provider Business Mailing Address Fax Number:
888-975-0599

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2785 S BAY ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUSTIS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32726-6591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-668-6222
Provider Business Practice Location Address Fax Number:
888-975-0599
Provider Enumeration Date:
10/09/2014

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: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 022779900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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