MEDICARE: LACEY J BEASTON FNP

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	363LP2300X	Primary Care Nurse Practitioner	95017474	CA

General Provider Information

NPI Number	:	1962178731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACEY J BEASTON FNP

Provider Business Mailing Address
First Line	:	1320 KELLY ST
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92054-6412
Country	:	US
Telephone Number	:	760-717-5770
Fax Number	:

Provider Business Practice Location Address
First Line	:	1320 KELLY ST
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92054-6412
Country	:	US
Telephone Number	:	760-717-5770
Fax Number	:

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

Provider Enumeration Date	:	08/20/2021
Last Update Date	:	08/20/2021

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