Healthcare Provider Details

I. General information

NPI: 1639327125
Provider Name (Legal Business Name): KYNDAL ANN BEAVERS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EDGEMONT RD
WYTHEVILLE VA
24382-4337
US

IV. Provider business mailing address

100 EDGEMONT RD
WYTHEVILLE VA
24382-4337
US

V. Phone/Fax

Practice location:
  • Phone: 276-223-0558
  • Fax:
Mailing address:
  • Phone: 276-223-0558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101054837
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: