=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124640412
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE L BEATY OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2020
-----------------------------------------------------
Last Update Date | 11/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7320 SHALLOWFORD RD # RC
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37421-4941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-894-5300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 285 BEAN RD
-----------------------------------------------------
City | MC DONALD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37353-5106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-716-4831
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3830
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------