Healthcare Provider Details

I. General information

NPI: 1093853376
Provider Name (Legal Business Name): JENNIFER A BEVERLY RN C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3169 SECOND AVE EAST WCBHS
BIG STONE GAP VA
24219
US

IV. Provider business mailing address

PO BOX 9054
GRAY TN
37615-9054
US

V. Phone/Fax

Practice location:
  • Phone: 276-523-8300
  • Fax: 276-523-6964
Mailing address:
  • Phone: 423-467-3600
  • Fax: 423-467-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001115351
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: