Healthcare Provider Details

I. General information

NPI: 1720404205
Provider Name (Legal Business Name): ANGEL SHELTON BEAVERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2014
Last Update Date: 01/19/2023
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1613 OAKWOOD ST
BEDFORD VA
24523-1213
US

IV. Provider business mailing address

6255 BETHANY ROAD
RUSTBURG VA
24588
US

V. Phone/Fax

Practice location:
  • Phone: 800-554-5517
  • Fax:
Mailing address:
  • Phone: 434-258-4426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001178518
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024171546
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: