Basic Information
| Provider Information | |||||||||
| NPI: | 1144467705 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAVER | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 487 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473750487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659838000 | ||||||||
| FaxNumber: | 7659838609 | ||||||||
| Practice Location | |||||||||
| Address1: | 831 DILLON DR | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473748048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659838000 | ||||||||
| FaxNumber: | 7659838609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2009 | ||||||||
| LastUpdateDate: | 01/19/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 28132815A | IN | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 28132815A | 01 | IN | RN | OTHER |