Healthcare Provider Details

I. General information

NPI: 1366175846
Provider Name (Legal Business Name): MISS HEATHER S BEAUPRE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2022
Last Update Date: 07/02/2022
Certification Date: 06/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7107 STAGECOACH RD.
CONESUS NY
14435
UM

IV. Provider business mailing address

7107 STAGECOACH RD.
CONESUS NY
14435
UM

V. Phone/Fax

Practice location:
  • Phone: 585-519-2055
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1399846
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: