Healthcare Provider Details

I. General information

NPI: 1255745501
Provider Name (Legal Business Name): ANNELIESE MARCELLE BEAUBRUN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2014
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 WESTON RD
WESTON FL
33331-3602
US

IV. Provider business mailing address

3100 WESTON RD STE 101
WESTON FL
33331-3602
US

V. Phone/Fax

Practice location:
  • Phone: 954-659-5883
  • Fax:
Mailing address:
  • Phone: 954-659-5883
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD15740
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN20056
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME159521
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: