=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033201009
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETH D. AVERSA ARNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 N BROADWAY SUITE A-3
-----------------------------------------------------
City | EVERETT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98201-1586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-317-0300
-----------------------------------------------------
Fax | 425-317-0303
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1166
-----------------------------------------------------
City | EVERETT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98206-1166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-258-7357
-----------------------------------------------------
Fax | 425-258-7022
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | AP30002374
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------