Healthcare Provider Details

I. General information

NPI: 1699075960
Provider Name (Legal Business Name): AUTUMN BEASLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 9TH ST SUITE 360
LUBBOCK TX
79415-3300
US

IV. Provider business mailing address

5219 CITY BANK PKWY STE 135
LUBBOCK TX
79407-3595
US

V. Phone/Fax

Practice location:
  • Phone: 806-761-0747
  • Fax: 806-761-0751
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number737829
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: