Healthcare Provider Details

I. General information

NPI: 1417283250
Provider Name (Legal Business Name): LAVINA BEVERIDGE APN 0995188
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAVINA BEVERIDGE RN 112197

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 11/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 BROADWAY
EAGLE CO
81631
US

IV. Provider business mailing address

PO BOX 1406
EAGLE CO
81631-1406
US

V. Phone/Fax

Practice location:
  • Phone: 970-328-8840
  • Fax: 970-328-8829
Mailing address:
  • Phone: 970-390-8344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number112197
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0995188
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: