Healthcare Provider Details

I. General information

NPI: 1457750754
Provider Name (Legal Business Name): BEVERLY DISHMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2014
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6448 TOLHURST CT
ANCHORAGE AK
99504-4450
US

IV. Provider business mailing address

6448 TOLHURST CT
ANCHORAGE AK
99504-4450
US

V. Phone/Fax

Practice location:
  • Phone: 907-317-9259
  • Fax:
Mailing address:
  • Phone: 907-317-9259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number27864
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: