Healthcare Provider Details

I. General information

NPI: 1942387592
Provider Name (Legal Business Name): BEVERLY JO MARIEN RN,CNOR, CRNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1144 NEW BALLWIN OAKS DR
BALLWIN MO
63021-4472
US

IV. Provider business mailing address

4400 LINDELL BLVD SUITE 21H
SAINT LOUIS MO
63108-2452
US

V. Phone/Fax

Practice location:
  • Phone: 636-394-6717
  • Fax: 636-394-6717
Mailing address:
  • Phone: 314-531-1455
  • Fax: 314-531-1455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number123589
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: