Healthcare Provider Details

I. General information

NPI: 1497315121
Provider Name (Legal Business Name): WILDA B BEAUVAIS DR.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2019
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6453 PEMBROKE RD
HOLLYWOOD FL
33023-2137
US

IV. Provider business mailing address

6453 PEMBROKE RD FL 33025
HOLLYWOOD FL
33023-2137
US

V. Phone/Fax

Practice location:
  • Phone: 954-559-4066
  • Fax:
Mailing address:
  • Phone: 954-859-6294
  • Fax: 954-859-6152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN9435744
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: