Healthcare Provider Details

I. General information

NPI: 1881163897
Provider Name (Legal Business Name): JODY GERMAINE BEAUDOIN AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WASHINGTON ST
ELMIRA NY
14901-2849
US

IV. Provider business mailing address

1065 SUGAR HILL RD
BEAVER DAMS NY
14812-9741
US

V. Phone/Fax

Practice location:
  • Phone: 607-737-4700
  • Fax: 607-737-9080
Mailing address:
  • Phone: 607-684-0050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF308953-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: