Healthcare Provider Details

I. General information

NPI: 1629178769
Provider Name (Legal Business Name): RITA CAROL BEASLEY ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 HIGHWAY 35 S
FOREST MS
39074-5010
US

IV. Provider business mailing address

4415 HENDERSON RD
JACKSON MS
39272-5669
US

V. Phone/Fax

Practice location:
  • Phone: 601-469-9999
  • Fax: 601-469-9933
Mailing address:
  • Phone: 601-372-5843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR561193
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: