Healthcare Provider Details

I. General information

NPI: 1962709683
Provider Name (Legal Business Name): BEVERLY JOY LA MADRID CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2011
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 W HART RD
BELOIT WI
53511-2230
US

IV. Provider business mailing address

3005 S RIVERSIDE DR STE 206
BELOIT WI
53511-1500
US

V. Phone/Fax

Practice location:
  • Phone: 608-362-7444
  • Fax:
Mailing address:
  • Phone: 608-362-7444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR128766
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: