Healthcare Provider Details

I. General information

NPI: 1639261555
Provider Name (Legal Business Name): NINA BEACH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W 5TH ST
SHERIDAN WY
82801-2705
US

IV. Provider business mailing address

1401 W 5TH ST
SHERIDAN WY
82801-2705
US

V. Phone/Fax

Practice location:
  • Phone: 307-674-6022
  • Fax: 307-674-5405
Mailing address:
  • Phone: 307-674-6022
  • Fax: 307-674-5405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number23523.0843
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: