Basic Information
Provider Information | |||||||||
NPI: | 1811993264 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BEACH | ||||||||
FirstName: | LAURIE | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 271430 | ||||||||
Address2: |   | ||||||||
City: | FORT COLLINS | ||||||||
State: | CO | ||||||||
PostalCode: | 805271430 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9704881640 | ||||||||
FaxNumber: | 9704729381 | ||||||||
Practice Location | |||||||||
Address1: | 212 COLLEGE ST | ||||||||
Address2: |   | ||||||||
City: | PILOT GROVE | ||||||||
State: | MO | ||||||||
PostalCode: | 652761005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6608313728 | ||||||||
FaxNumber: | 6608313326 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/21/2005 | ||||||||
LastUpdateDate: | 02/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 110297 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 000082595 | 01 | MO | MEDICARE NUMBER | OTHER | 001014600 | 01 | MO | MEDICARE PART B | OTHER |