MEDICARE: MS. LAURA NANCE BEVERLY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	ME59866	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235189861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAURA NANCE BEVERLY M.D.

Provider Business Mailing Address
First Line	:	900 UNIVERSITY BLVD. NORTH
Second Line	:	MC 75
City	:	JACKSONVILLE
State	:	FL
Zip	:	32211
Country	:	US
Telephone Number	:	904-253-2062
Fax Number	:	904-253-1942

Provider Business Practice Location Address
First Line	:	1522 PENMAN RD.
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250
Country	:	US
Telephone Number	:	904-253-2555
Fax Number	:	904-270-2559

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	01/02/2013

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